Provider Demographics
NPI:1568636207
Name:BRENT W FIDLER
Entity Type:Organization
Organization Name:BRENT W FIDLER
Other - Org Name:EISENHOWER EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:W
Authorized Official - Last Name:FIDLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-667-2954
Mailing Address - Street 1:1524 W EISENHOWER BLVD
Mailing Address - Street 2:STE. C
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-3112
Mailing Address - Country:US
Mailing Address - Phone:970-667-2954
Mailing Address - Fax:970-663-4713
Practice Address - Street 1:1524 W EISENHOWER BLVD
Practice Address - Street 2:STE. C
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-3112
Practice Address - Country:US
Practice Address - Phone:970-667-2954
Practice Address - Fax:970-663-4713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCG7008Medicare PIN