Provider Demographics
NPI:1598775140
Name:FEDORKO, TRUDY E (DO)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:E
Last Name:FEDORKO
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 1:4040 N CENTRAL EXPWAY
Mailing Address - Street 2:#600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-3147
Mailing Address - Country:US
Mailing Address - Phone:214-520-5743
Mailing Address - Fax:214-520-5786
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:MMC DALLAS
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203
Practice Address - Country:US
Practice Address - Phone:214-942-5733
Practice Address - Fax:214-942-6115
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4317207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136657702Medicaid
TX82957FOtherBLUE CROSS BLUE SHIELD
TX82957FMedicare PIN
TX136657702Medicaid
TX82957FOtherBLUE CROSS BLUE SHIELD
TXP00044774Medicare PIN