Provider Demographics
NPI:1538364237
Name:FEDULLO, JOHN LEWIS (D O)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEWIS
Last Name:FEDULLO
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4988 STATE HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7520
Mailing Address - Country:US
Mailing Address - Phone:518-841-3481
Mailing Address - Fax:518-841-3582
Practice Address - Street 1:4988 STATE HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7520
Practice Address - Country:US
Practice Address - Phone:518-841-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197917207R00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1720051428OtherGROUP NPI
NY01762629Medicaid
NY01762629Medicaid
NY1720051428OtherGROUP NPI