Provider Demographics
NPI:1912192436
Name:FEDUS, STEPHEN F III (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:F
Last Name:FEDUS
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 HARTFORD TPK.
Mailing Address - Street 2:SEARS OPTICAL DEPT.
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385
Mailing Address - Country:US
Mailing Address - Phone:860-447-5379
Mailing Address - Fax:
Practice Address - Street 1:824 HARTFORD TPK.
Practice Address - Street 2:SEARS OPTICAL DEPT.
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385
Practice Address - Country:US
Practice Address - Phone:860-447-5379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2389152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT59229Medicare UPIN