Provider Demographics
NPI:1336315043
Name:FODERICK, PETER PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:PAUL
Last Name:FODERICK
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 1:506 FOURTH AVE.W
Mailing Address - Street 2:P.O.BOX189
Mailing Address - City:ADA
Mailing Address - State:MN
Mailing Address - Zip Code:56510-0189
Mailing Address - Country:US
Mailing Address - Phone:218-784-4848
Mailing Address - Fax:
Practice Address - Street 1:506 4TH AVE W
Practice Address - Street 2:506 FOURTH AVE.W
Practice Address - City:ADA
Practice Address - State:MN
Practice Address - Zip Code:56510-1011
Practice Address - Country:US
Practice Address - Phone:218-784-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13953208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND48557Medicare UPIN