Provider Demographics
NPI:1336489061
Name:FIDLER, MICHAEL DENNIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DENNIS
Last Name:FIDLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2523 EL PORTAL DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3305
Mailing Address - Country:US
Mailing Address - Phone:510-215-3700
Mailing Address - Fax:510-215-3791
Practice Address - Street 1:2523 EL PORTAL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3305
Practice Address - Country:US
Practice Address - Phone:510-215-3700
Practice Address - Fax:510-215-3791
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-16
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC340922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry