Provider Demographics
NPI:1578674800
Name:NEIDERER, KATHERINE MARIE (DPM)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:NEIDERER
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 1:10936 WESTWARD PL
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5787
Mailing Address - Country:US
Mailing Address - Phone:520-548-5573
Mailing Address - Fax:520-629-4962
Practice Address - Street 1:10936 WESTWARD PL
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5787
Practice Address - Country:US
Practice Address - Phone:520-548-5573
Practice Address - Fax:520-629-4962
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ606213E00000X
VA0103301097213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ405765Medicaid
AZZ128402Medicare PIN