Provider Demographics
NPI:1255545315
Name:FREDERICK, REGINALD AUGUSTUS (CST,CSA)
Entity type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:AUGUSTUS
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:CST,CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761ST TANK BN. AVE, BLDG.332
Mailing Address - Street 2:PO BOX 5865
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-0865
Mailing Address - Country:US
Mailing Address - Phone:254-699-1434
Mailing Address - Fax:
Practice Address - Street 1:CARL R. DARNALL ARMY MEDICAL CENTER
Practice Address - Street 2:36065 SANTA FE AVENUE
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-4752
Practice Address - Country:US
Practice Address - Phone:254-618-7508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSA0076246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant