Provider Demographics
NPI:1518057314
Name:FREDERIKSEN, KIRSTEN E (MD)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:E
Last Name:FREDERIKSEN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:E
Other - Last Name:FREDERIKSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-2000
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16719207RB0002X, 207RB0002X
FLME80180208600000X
IN01075779A207RB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ963137Medicaid
IN201313100Medicaid
INP01588213OtherRR MEDICARE
IN266180591Medicare PIN
AZG69065Medicare UPIN
AZ963137Medicaid
INP01588213OtherRR MEDICARE