Provider Demographics
NPI:1780796722
Name:FEDDERS, DAVID LEO (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEO
Last Name:FEDDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W 4TH ST
Mailing Address - Street 2:RM 2250
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-3604
Mailing Address - Country:US
Mailing Address - Phone:513-723-0390
Mailing Address - Fax:513-723-0480
Practice Address - Street 1:1 W 4TH ST
Practice Address - Street 2:RM 2250
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-3604
Practice Address - Country:US
Practice Address - Phone:513-723-0390
Practice Address - Fax:513-723-0480
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034451101YM0800X
OH04451174400000X
IN01075325A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0368927Medicaid
IN968950004Medicare UPIN
OHFE 0398224Medicare UPIN
OH0368927Medicaid