Provider Demographics
NPI:1609866334
Name:FETCHIK, ANDREW ALEXANDER (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:ALEXANDER
Last Name:FETCHIK
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 1:307 BOATNER RD STE 114
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1302
Mailing Address - Country:US
Mailing Address - Phone:850-883-8600
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD STE 114
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1302
Practice Address - Country:US
Practice Address - Phone:850-883-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203148207Q00000X
FLOS6553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40171Medicare ID - Type UnspecifiedMEDICARE FL GROUP#
FL57195Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
FLF70602Medicare UPIN