Provider Demographics
NPI:1689642779
Name:FIEDERLEIN, JOHN F (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:FIEDERLEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:1411 S CREASY LN
Practice Address - Street 2:SUITE 130
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-7438
Practice Address - Country:US
Practice Address - Phone:765-447-7447
Practice Address - Fax:765-807-0553
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055952A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000220414OtherANTHEM PROVIDER NUMBER
IN200394920Medicaid
IN815150EMedicare PIN
IN000000220414OtherANTHEM PROVIDER NUMBER
IN300131377Medicare PIN