Healthcare Provider Details

I. General information

NPI: 1336489061
Provider Name (Legal Business Name): MICHAEL DENNIS FIDLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2013
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2523 EL PORTAL DR SUITE 101
SAN PABLO CA
94806-3305
US

IV. Provider business mailing address

2523 EL PORTAL DR SUITE 101
SAN PABLO CA
94806-3305
US

V. Phone/Fax

Practice location:
  • Phone: 510-215-3700
  • Fax: 510-215-3791
Mailing address:
  • Phone: 510-215-3700
  • Fax: 510-215-3791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC34092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: