Provider Demographics
NPI:1134242563
Name:FEDORYK, ANTHONY G (DC)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:G
Last Name:FEDORYK
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 1:4019 WESTERLY PL STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2343
Mailing Address - Country:US
Mailing Address - Phone:949-250-1125
Mailing Address - Fax:949-250-5841
Practice Address - Street 1:4019 WESTERLY PL STE 101
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2343
Practice Address - Country:US
Practice Address - Phone:949-250-1125
Practice Address - Fax:949-250-5841
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28888111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor