Provider Demographics
NPI:1184749061
Name:FIEDLER, VIRGINIA CAROL (MD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:CAROL
Last Name:FIEDLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 LAKE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1480
Mailing Address - Country:US
Mailing Address - Phone:847-920-1700
Mailing Address - Fax:847-920-1739
Practice Address - Street 1:1921 LAKE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1480
Practice Address - Country:US
Practice Address - Phone:847-920-1700
Practice Address - Fax:847-920-1739
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052338207N00000X
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E49805Medicare UPIN