Provider Demographics
NPI:1548349871
Name:FEDORIW, WIACHESLAW WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:WIACHESLAW
Middle Name:WILLIAM
Last Name:FEDORIW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3030 LAKE AVE
Mailing Address - Street 2:#25A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5428
Mailing Address - Country:US
Mailing Address - Phone:260-422-4096
Mailing Address - Fax:260-424-2551
Practice Address - Street 1:2710 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5412
Practice Address - Country:US
Practice Address - Phone:260-373-8070
Practice Address - Fax:260-373-8071
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10137509208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10013063AMedicaid
IN10013063Medicaid