Basic Information
| Provider Information | |||||||||
| NPI: | 1942566252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIDLER | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3 RIVERSIDE CIR | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240164955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407251226 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 RIVERSIDE CIR | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240164955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407251226 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2012 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 0103301175 | VA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | 0103301175 | VA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 1942566252 | 01 | VA | CIGNA | OTHER | 1942566252 | 01 | VA | HEALTHKEEPERS | OTHER | 1942566252 | 01 | VA | VA PREMIER | OTHER | 1942566252 | 01 | VA | UMWA | OTHER | 1942566252 | 01 | VA | ANTHEM | OTHER | 1942566252 | 01 | VA | HUMANA MEDICARE | OTHER | 1942566252 | 05 | VA | MEDICAID | 1942566252 | 01 | VA | GATEWAY | OTHER | 1942566252 | 01 | VA | AETNA | OTHER | 540506332108 | 01 | VA | TRICARE | OTHER | 1942566252 | 01 | VA | OPTIMA HEALTH PLAN | OTHER | 1942566252 | 01 | VA | UNITED HEALTHCARE | OTHER | 1942566252 | 01 | VA | HEALTHKEEPERS PLUS | OTHER |