Individual
MR. PETER JOHN FEDORA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
L.O.
Contact information
Practice address
236 N MAIN ST, MANCHESTER, CT 06042-2004
(860) 646-3577
(860) 643-9733
Mailing address
25 WHITE RD, TOLLAND, CT 06084-2541
(860) 646-3577
(860) 643-9733
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
000601
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
06-1198912
FEDERAL TAXPAYER ID
CT
Enumeration date
04/04/2007
Last updated
07/08/2007
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