Provider Demographics
NPI:1093879629
Name:DAVID F. FETTERMAN, O.D.P.C.
Entity Type:Organization
Organization Name:DAVID F. FETTERMAN, O.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:FETTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-742-7507
Mailing Address - Street 1:23 S ARCH ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:PA
Mailing Address - Zip Code:17847-1142
Mailing Address - Country:US
Mailing Address - Phone:570-742-7507
Mailing Address - Fax:570-742-1884
Practice Address - Street 1:23 S ARCH ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:PA
Practice Address - Zip Code:17847-1142
Practice Address - Country:US
Practice Address - Phone:570-742-7507
Practice Address - Fax:570-742-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001596152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0729480001Medicare NSC
PA127050Medicare PIN
PA1093879629Medicare NSC