Provider Demographics
NPI:1093158495
Name:FETCH, AUDREY SZEP (MD)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:SZEP
Last Name:FETCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:SZEP
Other - Last Name:VASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1225 CRANE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4253
Mailing Address - Country:US
Mailing Address - Phone:650-323-0276
Mailing Address - Fax:
Practice Address - Street 1:1225 CRANE ST STE 102
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025
Practice Address - Country:US
Practice Address - Phone:650-323-0276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA147626207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology