Provider Demographics
NPI:1164542437
Name:FIDLER, JOHN MARTIN (OWNER OF SHOE STORE)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARTIN
Last Name:FIDLER
Suffix:
Gender:M
Credentials:OWNER OF SHOE STORE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:GETTYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17325
Mailing Address - Country:US
Mailing Address - Phone:717-334-1810
Mailing Address - Fax:717-334-1810
Practice Address - Street 1:26 BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325
Practice Address - Country:US
Practice Address - Phone:717-334-1810
Practice Address - Fax:717-334-1810
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4132010001Medicare UPIN