Healthcare Provider Details

I. General information

NPI: 1679139315
Provider Name (Legal Business Name): HEATHER RENEE FRIDEGER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 FAIRINGTON DR
SIDNEY OH
45365-8913
US

IV. Provider business mailing address

53 S GARFIELD ST
MINSTER OH
45865-1341
US

V. Phone/Fax

Practice location:
  • Phone: 937-492-9197
  • Fax:
Mailing address:
  • Phone: 567-644-8907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.006745
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: