Provider Demographics
NPI:1417989682
Name:FEDER, JAY MITCHELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:MITCHELL
Last Name:FEDER
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 1:3611 SWEETHORN CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1226
Mailing Address - Country:US
Mailing Address - Phone:703-517-2415
Mailing Address - Fax:
Practice Address - Street 1:3611 SWEETHORN CT
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1226
Practice Address - Country:US
Practice Address - Phone:703-517-2415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2337522085R0202X
NJ25MA089827002085R0202X
VA0101044480208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02798507Medicaid
NYD35615Medicare UPIN
NY02798507Medicaid