Provider Demographics
NPI:1942566252
Name:FIDLER, COREY MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:MICHAEL
Last Name:FIDLER
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-725-1226
Practice Address - Fax:540-857-5306
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301175213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1942566252OtherOPTIMA HEALTH PLAN
VA1942566252OtherHUMANA MEDICARE
VA540506332108OtherTRICARE
VA1942566252OtherVA PREMIER
VA1942566252OtherHEALTHKEEPERS
VA1942566252OtherCIGNA
VA1942566252OtherANTHEM
VA1942566252OtherUNITED HEALTHCARE
VA1942566252OtherGATEWAY
VA1942566252OtherAETNA
VA1942566252OtherHEALTHKEEPERS PLUS
VA1942566252OtherUMWA
VA1942566252Medicaid