Provider Demographics
NPI:1659711349
Name:FEDDERSEN, GARRETT JAMES (DO)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:JAMES
Last Name:FEDDERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 WEST 5TH ST PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588
Mailing Address - Country:US
Mailing Address - Phone:712-213-8676
Mailing Address - Fax:
Practice Address - Street 1:1525 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588
Practice Address - Country:US
Practice Address - Phone:712-213-8676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-04574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine