Provider Demographics
NPI:1306847488
Name:FATZ, CASEY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:JOHN
Last Name:FATZ
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 1:700 W IRONWOOD DR STE 175
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4401
Mailing Address - Country:US
Mailing Address - Phone:208-625-6309
Mailing Address - Fax:208-625-6310
Practice Address - Street 1:700 W IRONWOOD DR STE 175
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-6309
Practice Address - Fax:208-625-6310
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-90342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806865100Medicaid
ID806865100Medicaid
P00129223Medicare PIN
H61150Medicare UPIN