1558721704 NPI number — IRINA FEDULOW D.P.T.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558721704 NPI number — IRINA FEDULOW D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEDULOW
Provider First Name:
IRINA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558721704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1291 MARSHALL ST
Provider Second Line Business Mailing Address:
ROOM 104A WILLOW BUILDING
Provider Business Mailing Address City Name:
REDWOOD CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94063-2531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1291 MARSHALL ST
Provider Second Line Business Practice Location Address:
104A WILLOW BUILDING
Provider Business Practice Location Address City Name:
REDWOOD CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94063-2531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-299-4854
Provider Business Practice Location Address Fax Number:
650-299-4828
Provider Enumeration Date:
03/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  43051 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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