Provider Demographics
NPI:1043207434
Name:FETTERS, SHEILA M (OD)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:M
Last Name:FETTERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 DEER WOODS DR NE
Mailing Address - Street 2:
Mailing Address - City:SWISHER
Mailing Address - State:IA
Mailing Address - Zip Code:52338-9436
Mailing Address - Country:US
Mailing Address - Phone:319-841-5030
Mailing Address - Fax:
Practice Address - Street 1:2600 EDGEWOOD RD SW
Practice Address - Street 2:SUITE 376
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-7818
Practice Address - Country:US
Practice Address - Phone:319-390-4144
Practice Address - Fax:319-390-4674
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA2049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA202664232OtherCOMMERCIAL
IA45822OtherBLUE CROSS BLUE SHIELD
IA45822OtherBLUE CROSS BLUE SHIELD
IAI15981Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
IA202664232OtherCOMMERCIAL