Provider Demographics
NPI:1982698510
Name:FIEGE, JOHN C (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:FIEGE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 SELVA LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-7326
Mailing Address - Country:US
Mailing Address - Phone:904-349-0990
Mailing Address - Fax:904-246-1578
Practice Address - Street 1:1241 MAYPORT RD
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-3435
Practice Address - Country:US
Practice Address - Phone:904-349-0990
Practice Address - Fax:904-246-1578
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0007180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ14093Medicare UPIN
FLY4214Medicare ID - Type Unspecified