Provider Demographics
NPI:1710957048
Name:FEDRO, DAVID JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:FEDRO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:688 ALLIANCE PKWY
Mailing Address - Street 2:SUITE #201
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643-3585
Mailing Address - Country:US
Mailing Address - Phone:254-300-4399
Mailing Address - Fax:254-300-4401
Practice Address - Street 1:688 ALLIANCE PKWY
Practice Address - Street 2:SUITE #201
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3585
Practice Address - Country:US
Practice Address - Phone:254-300-4399
Practice Address - Fax:254-300-4401
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG3347208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138516315Medicaid
TX167931802Medicaid
TX0815318-01Medicaid
TX167931801Medicaid
TX167931801Medicaid
TX167931802Medicaid
TX8J4549Medicare PIN
TX138516315Medicaid
TX8L3539Medicare PIN
TX00A27WMedicare PIN