Provider Demographics
NPI:1053529156
Name:FIDELIE, JOSEPH JOHN (AT,C)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JOHN
Last Name:FIDELIE
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GARRISON LN
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6784
Mailing Address - Country:US
Mailing Address - Phone:405-265-0426
Mailing Address - Fax:405-265-3715
Practice Address - Street 1:800 GARRISON LN
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6784
Practice Address - Country:US
Practice Address - Phone:405-265-0426
Practice Address - Fax:405-265-3715
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer