Provider Demographics
NPI:1033177415
Name:FIESSELER, FREDERICK (DO)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:FIESSELER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7313
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-7313
Mailing Address - Country:US
Mailing Address - Phone:800-290-5309
Mailing Address - Fax:803-434-4354
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:800-290-5309
Practice Address - Fax:803-434-4354
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB71344207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8363706Medicaid
NJ047002M8YMedicare ID - Type Unspecified
NJ8363706Medicaid