Provider Demographics
NPI:1871710160
Name:FEDDERSEN, MICHAEL HORST (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HORST
Last Name:FEDDERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 BROADWAY ST
Mailing Address - Street 2:SUITE B5
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1229
Mailing Address - Country:US
Mailing Address - Phone:707-561-9005
Mailing Address - Fax:
Practice Address - Street 1:3433 BROADWAY ST
Practice Address - Street 2:SUITE B5
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-1229
Practice Address - Country:US
Practice Address - Phone:707-561-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB078936002084P0800X
CA20A95852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry