Provider Demographics
NPI:1124025721
Name:FETROE, DALE T (MD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:T
Last Name:FETROE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 EPHRATA
Mailing Address - Street 2:C/O COYOTE RIDGE CORRECTION CENTER
Mailing Address - City:CONNELL
Mailing Address - State:WA
Mailing Address - Zip Code:99326
Mailing Address - Country:US
Mailing Address - Phone:509-543-5903
Mailing Address - Fax:
Practice Address - Street 1:1301 EPHRATA
Practice Address - Street 2:C/O COYOTE RIDGE CORRECTION CENTER
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326
Practice Address - Country:US
Practice Address - Phone:509-543-5903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA080173711OtherRAILROAD MEDICARE
OR239467Medicaid
WA1111855Medicaid
WA1111855Medicaid
OR239467Medicaid