Provider Demographics
NPI:1871588186
Name:FETTER, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:FETTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4917
Mailing Address - Country:US
Mailing Address - Phone:847-599-9500
Mailing Address - Fax:847-599-9485
Practice Address - Street 1:2626 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4917
Practice Address - Country:US
Practice Address - Phone:847-599-9500
Practice Address - Fax:847-599-9485
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2010-08-18
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IL036057645174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL225340Medicare ID - Type Unspecified
ILC43737Medicare UPIN