Healthcare Provider Details

I. General information

NPI: 1316280282
Provider Name (Legal Business Name): DIETER FELLNER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 BROADWAY AVE
GORHAM NH
03581-1502
US

IV. Provider business mailing address

2 BROADWAY AVE
GORHAM NH
03581-1502
US

V. Phone/Fax

Practice location:
  • Phone: 603-466-2741
  • Fax:
Mailing address:
  • Phone: 603-466-2741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN006747
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0385
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: