Provider Demographics
NPI:1972892586
Name:ROBERT G FIDLER DPM INC
Entity type:Organization
Organization Name:ROBERT G FIDLER DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:FIDLER
Authorized Official - Suffix:SR
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-625-0865
Mailing Address - Street 1:2309 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4827
Mailing Address - Country:US
Mailing Address - Phone:419-625-0865
Mailing Address - Fax:419-625-1811
Practice Address - Street 1:2309 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4827
Practice Address - Country:US
Practice Address - Phone:419-625-0865
Practice Address - Fax:419-625-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001211213E00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0140970001Medicare NSC
OH0010931Medicare PIN