Provider Demographics
NPI:1417067851
Name:FIDLER, CRAIG ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALLEN
Last Name:FIDLER
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 1:2120 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-3545
Mailing Address - Country:US
Mailing Address - Phone:954-467-3777
Mailing Address - Fax:954-463-7643
Practice Address - Street 1:2120 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-3545
Practice Address - Country:US
Practice Address - Phone:954-467-3777
Practice Address - Fax:954-463-7643
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001638152W00000X
FLOPC1638152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC1638OtherFL BOARD CERTIFICATION #
FLT84151Medicare UPIN
FL0486950001Medicare NSC
FLOPC1638OtherFL BOARD CERTIFICATION #
FL19209Medicare PIN