Provider Demographics
NPI:1467547661
Name:FEDORCUK, ANGELA (DPM)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FEDORCUK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 HOPE STREET
Mailing Address - Street 2:SUITE 6
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-5210
Mailing Address - Country:US
Mailing Address - Phone:401-254-0922
Mailing Address - Fax:401-254-8894
Practice Address - Street 1:970 HOPE STREET
Practice Address - Street 2:SUITE 6
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-5210
Practice Address - Country:US
Practice Address - Phone:401-254-0922
Practice Address - Fax:401-254-8894
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM260213E00000X
MA1941213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2700166OtherUNITED HEALTHCARE
RI9007059Medicaid
RI70599OtherBLUE CROSS BLUE SHIELD
RI9007059Medicaid