Provider Demographics
NPI:1912037664
Name:FEDAK, GAIL A (OD)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:A
Last Name:FEDAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 N ST CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077
Mailing Address - Country:US
Mailing Address - Phone:440-352-3339
Mailing Address - Fax:440-352-0013
Practice Address - Street 1:70 N ST CLAIR ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077
Practice Address - Country:US
Practice Address - Phone:440-352-3339
Practice Address - Fax:440-352-0013
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH428OtherDEA
FE0602651Medicare ID - Type Unspecified