Healthcare Provider Details

I. General information

NPI: 1164542437
Provider Name (Legal Business Name): JOHN MARTIN FIDLER OWNER OF SHOE STORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 BALTIMORE ST
GETTYSBURG PA
17325
US

IV. Provider business mailing address

26 BALTIMORE ST
GETTYSBURG PA
17325
US

V. Phone/Fax

Practice location:
  • Phone: 717-334-1810
  • Fax: 717-334-1810
Mailing address:
  • Phone: 717-334-1810
  • Fax: 717-334-1810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: