Provider Demographics
NPI:1881956530
Name:FEDEWA, MICHAEL J JR (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:FEDEWA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:NAVAL HOSPITAL
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4389 BEAUFORT RD
Practice Address - Street 2:NAVAL HEALTH CLINIC
Practice Address - City:CHERRY POINT
Practice Address - State:NC
Practice Address - Zip Code:28533-2100
Practice Address - Country:US
Practice Address - Phone:910-450-4159
Practice Address - Fax:910-450-4194
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2013-01911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program