Provider Demographics
NPI:1710987300
Name:FIEDLER, JODI ALLENE (MD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ALLENE
Last Name:FIEDLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21020 STATE ROAD 7
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1320
Mailing Address - Country:US
Mailing Address - Phone:561-883-5640
Mailing Address - Fax:561-409-4010
Practice Address - Street 1:21020 STATE ROAD 7
Practice Address - Street 2:SUITE 120
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1320
Practice Address - Country:US
Practice Address - Phone:561-883-5640
Practice Address - Fax:561-409-4010
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80070207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2548084OtherAETNA PROVIDER ID
FL2200779OtherGHI PROVIDER ID
FL261302600Medicaid
FL261302600Medicaid
FLG92120Medicare UPIN
FL2200779OtherGHI PROVIDER ID