1043207434 NPI number — SHEILA M FETTERS OD

Table of content: SHEILA M FETTERS OD (NPI 1043207434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043207434 NPI number — SHEILA M FETTERS OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FETTERS
Provider First Name:
SHEILA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043207434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1433 DEER WOODS DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWISHER
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52338-9436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-841-5030
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 EDGEWOOD RD SW
Provider Second Line Business Practice Location Address:
SUITE 376
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52404-7818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-390-4144
Provider Business Practice Location Address Fax Number:
319-390-4674
Provider Enumeration Date:
09/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  IA2049 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202664232 . This is a "COMMERCIAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 45822 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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