Provider Demographics
NPI:1013912955
Name:FRIDERES, MARK DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:FRIDERES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 S G AVE
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-2778
Mailing Address - Country:US
Mailing Address - Phone:515-382-2128
Mailing Address - Fax:515-382-3617
Practice Address - Street 1:1229 S G AVE
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:IA
Practice Address - Zip Code:50201-2778
Practice Address - Country:US
Practice Address - Phone:515-382-2128
Practice Address - Fax:515-382-3617
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2012-08-17
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
IA06327111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0221424Medicaid
IA0221424Medicaid
IA22095Medicare UPIN
IA9584061001Medicare UPIN