Provider Demographics
NPI:1326256744
Name:FIEBIG, GARY ANDRE (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ANDRE
Last Name:FIEBIG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8354 RESEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4619
Mailing Address - Country:US
Mailing Address - Phone:818-701-5367
Mailing Address - Fax:818-886-0545
Practice Address - Street 1:8354 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4619
Practice Address - Country:US
Practice Address - Phone:818-701-5367
Practice Address - Fax:818-886-0545
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2428SL1193156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ82127ZMedicaid
CA0731610001Medicare NSC