Provider Demographics
NPI:1033700216
Name:FIDLER, DANIEL T
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:FIDLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-2823
Mailing Address - Country:US
Mailing Address - Phone:765-673-4327
Mailing Address - Fax:
Practice Address - Street 1:2040 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-2823
Practice Address - Country:US
Practice Address - Phone:765-673-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001244A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist