Provider Demographics
NPI:1114904547
Name:FETTIG, ROBERT WALTER (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WALTER
Last Name:FETTIG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4524 BABICH AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-1907
Mailing Address - Country:US
Mailing Address - Phone:916-736-1001
Mailing Address - Fax:916-736-9001
Practice Address - Street 1:1221 ALHAMBRA BLVD
Practice Address - Street 2:105
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5237
Practice Address - Country:US
Practice Address - Phone:916-451-5552
Practice Address - Fax:916-451-0756
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19113111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0191130Medicare ID - Type Unspecified
CADC0191130Medicare UPIN