Provider Demographics
NPI:1134215767
Name:NEIDERT, WILLIAM KONRAD JR (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KONRAD
Last Name:NEIDERT
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11568 HOOVER AVE NW
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-7385
Mailing Address - Country:US
Mailing Address - Phone:330-877-3645
Mailing Address - Fax:
Practice Address - Street 1:1515 PORTAGE ST NW
Practice Address - Street 2:SUITE C
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2290
Practice Address - Country:US
Practice Address - Phone:330-499-1518
Practice Address - Fax:330-499-7385
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1033111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0549366Medicaid
OH0549366Medicaid
OHT48030Medicare UPIN