Provider Demographics
NPI:1790899953
Name:FEDORUK, CHRISTOPHER DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:DANIEL
Last Name:FEDORUK
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 1:33910 THOUSAND OAK BLVD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-6268
Mailing Address - Country:US
Mailing Address - Phone:281-259-7286
Mailing Address - Fax:281-259-7286
Practice Address - Street 1:18951 N MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4217
Practice Address - Country:US
Practice Address - Phone:281-540-6453
Practice Address - Fax:281-540-7393
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0719207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173969005Medicaid
TX173969002Medicaid
TX173969003Medicaid
TX173969001Medicaid
TX8AC843OtherBCBSTX PROVIDER NO
TXI02262Medicare UPIN
TX173969005Medicaid
TX173969001Medicaid
TX173969003Medicaid
TX8D3582Medicare ID - Type Unspecified
TX173969002Medicaid