Healthcare Provider Details

I. General information

NPI: 1023295649
Provider Name (Legal Business Name): MR. CHRISTOPHER J FIDELI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SHADETREE LN
STONY BROOK NY
11790-3115
US

IV. Provider business mailing address

2 SHADETREE LN
STONY BROOK NY
11790-3115
US

V. Phone/Fax

Practice location:
  • Phone: 516-818-4435
  • Fax:
Mailing address:
  • Phone: 516-818-4435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number003006
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: