Provider Demographics
NPI:1235293150
Name:FIDDLER, BRIAN M (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:FIDDLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7840 E 96TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9629
Practice Address - Country:US
Practice Address - Phone:317-254-6480
Practice Address - Fax:317-259-8609
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003168152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1943018Medicare PIN
IN0873400005Medicare NSC
INU92738Medicare UPIN
IN894060LMedicare PIN