Provider Demographics
NPI:1063669471
Name:FEDORIW, WASYL WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:WASYL
Middle Name:WILLIAM
Last Name:FEDORIW
Suffix:
Gender:M
Credentials:MD
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 644006
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75264-4006
Mailing Address - Country:US
Mailing Address - Phone:713-650-6900
Mailing Address - Fax:713-650-4900
Practice Address - Street 1:1900 NORTH LOOP W STE 670
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018
Practice Address - Country:US
Practice Address - Phone:713-650-6900
Practice Address - Fax:713-650-4900
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050811207X00000X
TXP4162207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125050811OtherILLINOIS STATE LICENSE NUMBER
TXP4162OtherTEXAS MEDICAL LICENSE