Provider Demographics
NPI:1316675150
Name:FOSTER, NIDEO (DPT, PT)
Entity type:Individual
Prefix:
First Name:NIDEO
Middle Name:
Last Name:FOSTER
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4939 WISTERIA LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1741
Mailing Address - Country:US
Mailing Address - Phone:260-446-1630
Mailing Address - Fax:
Practice Address - Street 1:3731 W COOK RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9662
Practice Address - Country:US
Practice Address - Phone:260-215-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300066435Medicaid