Provider Demographics
NPI:1821289174
Name:NEIDECKER, JOHN MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:NEIDECKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27588-1107
Mailing Address - Country:US
Mailing Address - Phone:919-562-9410
Mailing Address - Fax:919-562-2948
Practice Address - Street 1:11200 GOVERNOR MANLY WAY STE 309
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-7375
Practice Address - Country:US
Practice Address - Phone:919-562-9410
Practice Address - Fax:919-562-2948
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ207Q00000X207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMB08631900OtherMEDICAL LICENSE