Provider Demographics
NPI:1659493021
Name:FEDORA, PETER JOHN (LO)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:FEDORA
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WHITE RD
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-2541
Mailing Address - Country:US
Mailing Address - Phone:860-646-3577
Mailing Address - Fax:860-643-9733
Practice Address - Street 1:236 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2004
Practice Address - Country:US
Practice Address - Phone:860-646-3577
Practice Address - Fax:860-643-9733
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000601156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT06-1198912OtherFEDERAL TAXPAYER ID
CT5020080001Medicare ID - Type Unspecified