Provider Demographics
NPI:1750507380
Name:FEDORA OPTICAL INC
Entity Type:Organization
Organization Name:FEDORA OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:FEDORA
Authorized Official - Suffix:
Authorized Official - Credentials:LO
Authorized Official - Phone:860-646-3577
Mailing Address - Street 1:236 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2004
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001359156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1750507380CTOtherANTHEM BLUE COSS BLUE SHIELD
CTCU6991OtherACH HEALTH NET
CTCU6991OtherACH HEALTH NET