Provider Demographics
NPI:1598861726
Name:FEDORKO, JEFFREY STEVEN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STEVEN
Last Name:FEDORKO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4774 MUNSON ST NW
Mailing Address - Street 2:#302
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3634
Mailing Address - Country:US
Mailing Address - Phone:330-494-0422
Mailing Address - Fax:330-494-3601
Practice Address - Street 1:4774 MUNSON ST NW
Practice Address - Street 2:#302
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3634
Practice Address - Country:US
Practice Address - Phone:330-494-0422
Practice Address - Fax:330-494-3601
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH919111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH645289Medicaid
T47470Medicare UPIN
OH645289Medicaid