Provider Demographics
NPI:1497757736
Name:FEDRIZZI, KRISELL D (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISELL
Middle Name:D
Last Name:FEDRIZZI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9552
Mailing Address - Country:US
Mailing Address - Phone:937-748-8026
Mailing Address - Fax:937-748-8030
Practice Address - Street 1:562 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066
Practice Address - Country:US
Practice Address - Phone:937-748-8026
Practice Address - Fax:937-748-8030
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004949F207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000227847OtherANTHEM
OH0769726Medicaid
OH0120677OtherUNITED HEALTHCARE
OH34004949FOtherMEDICAL LICENSE
OHD0494904OtherHUMANACHOICECARE
OH649246OtherAETNA
OH080191722OtherRAILROAD MEDICARE
OH421534506029OtherCARESOURCE
OH0769726Medicaid
OH000000227847OtherANTHEM