Provider Demographics
NPI:1790893832
Name:FESAK, DAVID MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:FESAK
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 1:1250 BUR OAK CT
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9476
Mailing Address - Country:US
Mailing Address - Phone:317-439-4334
Mailing Address - Fax:317-272-3228
Practice Address - Street 1:1250 BUR OAK CT
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9476
Practice Address - Country:US
Practice Address - Phone:317-439-4334
Practice Address - Fax:317-272-3228
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000972A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D69562Medicare UPIN