Provider Demographics
NPI:1295869832
Name:FEDUS, MARY W (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:W
Last Name:FEDUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:475 HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1524
Mailing Address - Country:US
Mailing Address - Phone:860-826-1052
Mailing Address - Fax:860-826-7047
Practice Address - Street 1:475 HARTFORD RD
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-1524
Practice Address - Country:US
Practice Address - Phone:860-826-1052
Practice Address - Fax:860-826-7047
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00#1003152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU56855Medicare UPIN