Provider Demographics
NPI:1366438848
Name:HUMPHREY, FREDERIC A (DO)
Entity type:Individual
Prefix:
First Name:FREDERIC
Middle Name:A
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:FREDERICK
Other - Middle Name:A
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:4727 STATE ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-5360
Mailing Address - Country:US
Mailing Address - Phone:740-374-4590
Mailing Address - Fax:740-568-0310
Practice Address - Street 1:4727 STATE ROUTE 60
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-5360
Practice Address - Country:US
Practice Address - Phone:740-374-4590
Practice Address - Fax:740-568-0310
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002561H207R00000X
WV671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000118170OtherANTHEM
WV0083356000Medicaid
OH0367802Medicaid
WV0083356000Medicaid
OH0367802Medicaid
WV0465522Medicare PIN
D89754Medicare UPIN