Basic Information
| Provider Information | |||||||||
| NPI: | 1568571461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEDOR | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1768 BUSINESS CENTER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201905359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007629244 | ||||||||
| FaxNumber: | 7866726006 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 HARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013872035 | ||||||||
| FaxNumber: | 8014751621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 7980120-1204 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 7980120-1204 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 7980120-1204 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.