Provider Demographics
NPI:1114474038
Name:FEDAK, DILLON (DPT)
Entity Type:Individual
Prefix:
First Name:DILLON
Middle Name:
Last Name:FEDAK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8840 CYPRESS WATERS BLVD
Mailing Address - Street 2:STE300
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4594
Mailing Address - Country:US
Mailing Address - Phone:866-217-8011
Mailing Address - Fax:
Practice Address - Street 1:8840 CYPRESS WATERS BLVD
Practice Address - Street 2:STE300
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4594
Practice Address - Country:US
Practice Address - Phone:866-217-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040504225100000X
IL070022752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist