Basic Information
| Provider Information | |||||||||
| NPI: | 1558579078 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JONATHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ELM AND CARLTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
| FaxNumber: | 7168457608 | ||||||||
| Practice Location | |||||||||
| Address1: | ELM AND CARLTON STREETS | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
| FaxNumber: | 7168457608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 256843 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 03241976 | 05 | NY | MEDICAID |