Provider Demographics
NPI:1528207156
Name:FEDYSZYN, CARL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:JOHN
Last Name:FEDYSZYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:166 19TH ST S
Mailing Address - Street 2:SUITE #201
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4654
Mailing Address - Country:US
Mailing Address - Phone:320-259-1405
Mailing Address - Fax:320-259-5896
Practice Address - Street 1:166 19TH ST S
Practice Address - Street 2:SUITE #201
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4654
Practice Address - Country:US
Practice Address - Phone:320-259-1405
Practice Address - Fax:320-259-5896
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2012-12-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ND7326207Q00000X
AZ37093207Q00000X
WAMD00048363207Q00000X
IDM-9986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine