Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 036140866 | IL |
N | 208800000X | Urologist | 125.059642 | IL |
NPI | 1043507866 |
---|---|
Provider Name | Dr. Luke Richard Frederick |
First Address | Rockford, IL 61107-5339 |
Second Address | Rockford, IL 61107-5339 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2011 |
Last Update Date | 21/06/2016 |