Provider Demographics
NPI:1942529714
Name:CRAIG A FIDLER OD PA
Entity Type:Organization
Organization Name:CRAIG A FIDLER OD PA
Other - Org Name:FIDLER EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FIDLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-467-3777
Mailing Address - Street 1:2120 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-3545
Mailing Address - Country:US
Mailing Address - Phone:954-467-3777
Mailing Address - Fax:954-463-7643
Practice Address - Street 1:2120 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-3545
Practice Address - Country:US
Practice Address - Phone:954-467-3777
Practice Address - Fax:954-463-7643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1638152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC1638OtherFLORIDA BOARD CERTIFICATION #
FL0486950001Medicare NSC
FLT84151Medicare UPIN
FL19209Medicare PIN