Provider Demographics
NPI:1417957333
Name:FEDORIW, NATALKA (MD)
Entity Type:Individual
Prefix:
First Name:NATALKA
Middle Name:
Last Name:FEDORIW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5529
Mailing Address - Country:US
Mailing Address - Phone:260-422-3937
Mailing Address - Fax:260-424-6900
Practice Address - Street 1:3301 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5529
Practice Address - Country:US
Practice Address - Phone:260-422-3937
Practice Address - Fax:260-424-6900
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060266A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200520580Medicaid
INP00229113OtherRR MEDICARE
IN137440DMedicare PIN
INP00229113OtherRR MEDICARE