Healthcare Provider Details

I. General information

NPI: 1457477440
Provider Name (Legal Business Name): BRENT W FIDLER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 W EISENHOWER BLVD STE C
LOVELAND CO
80537-4343
US

IV. Provider business mailing address

1524 W EISENHOWER BLVD STE C
LOVELAND CO
80537-4343
US

V. Phone/Fax

Practice location:
  • Phone: 970-667-2954
  • Fax: 866-858-0953
Mailing address:
  • Phone: 970-667-2954
  • Fax: 866-858-0953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1592
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: