Provider Demographics
NPI:1619331931
Name:NEIDECKER, KATIE (DPM)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:NEIDECKER
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 1:3733 PARK EAST DR STE 240
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4337
Mailing Address - Country:US
Mailing Address - Phone:216-245-1290
Mailing Address - Fax:866-571-4884
Practice Address - Street 1:3733 PARK EAST DR STE 240
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4337
Practice Address - Country:US
Practice Address - Phone:216-245-1290
Practice Address - Fax:866-571-4884
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000842213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist