Provider Demographics
NPI:1326074931
Name:FETTIG, TODD J (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:J
Last Name:FETTIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N RIVER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2646
Mailing Address - Country:US
Mailing Address - Phone:765-664-9637
Mailing Address - Fax:
Practice Address - Street 1:711 N RIVER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2646
Practice Address - Country:US
Practice Address - Phone:765-664-9637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002362A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100059630Medicaid
IN234950Medicare ID - Type Unspecified
INT83021Medicare UPIN