Provider Demographics
NPI:1457331522
Name:FETTERS HEALTH AND WELLNESS PC
Entity Type:Organization
Organization Name:FETTERS HEALTH AND WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:DVORAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-913-8170
Mailing Address - Street 1:11201 USA PARKWAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038
Mailing Address - Country:US
Mailing Address - Phone:317-913-8170
Mailing Address - Fax:317-913-8184
Practice Address - Street 1:11201 USA PARKWAY
Practice Address - Street 2:SUITE 205
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038
Practice Address - Country:US
Practice Address - Phone:317-913-8170
Practice Address - Fax:317-913-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034557A207N00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN311770DMedicare ID - Type Unspecified
E95260Medicare UPIN