Provider Demographics
NPI:1962610949
Name:FEDEWA, DUANE MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:DUANE
Middle Name:MICHAEL
Last Name:FEDEWA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 VINE ST
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-1621
Mailing Address - Country:US
Mailing Address - Phone:608-254-4731
Mailing Address - Fax:605-253-9257
Practice Address - Street 1:719 VINE ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1621
Practice Address - Country:US
Practice Address - Phone:608-254-4731
Practice Address - Fax:605-253-9257
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3031111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI350038138OtherRAILROAD MEDICARE
WIU48951Medicare UPIN
WI000070643Medicare ID - Type Unspecified