Provider Demographics
NPI:1891772653
Name:FODOR, PETER J (DPM)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:FODOR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 GRANDVIEW DR
Mailing Address - Street 2:STE 1
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-1635
Mailing Address - Country:US
Mailing Address - Phone:717-733-2251
Mailing Address - Fax:
Practice Address - Street 1:804 GRANDVIEW DR
Practice Address - Street 2:STE 1
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1635
Practice Address - Country:US
Practice Address - Phone:717-733-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004412L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA925809OtherHIGHMARK BLUE SHIELD
PA1520238OtherGATEWAY
PA0018417540003Medicaid
PA01320401OtherCAPITAL BLUE CROSS
PA01320401OtherCAPITAL BLUE CROSS
PA925809OtherHIGHMARK BLUE SHIELD
PA480033031Medicare PIN