Provider Demographics
NPI:1619068574
Name:GEORGE P. FEDOR, M.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GEORGE P. FEDOR, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:FEDOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-724-9657
Mailing Address - Street 1:1317 S DIAMOND BAR BLVD
Mailing Address - Street 2:4007
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-5679
Mailing Address - Country:US
Mailing Address - Phone:909-878-6665
Mailing Address - Fax:909-595-3705
Practice Address - Street 1:250 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4218
Practice Address - Country:US
Practice Address - Phone:626-857-3140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52838207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G63754Medicare UPIN
CAW21896Medicare PIN