Provider Demographics
NPI:1467440487
Name:FECHTNER, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:FECHTNER
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 1:235 WEALTHY ST SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5229
Mailing Address - Country:US
Mailing Address - Phone:616-840-8719
Mailing Address - Fax:616-840-9637
Practice Address - Street 1:235 WEALTHY ST SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5229
Practice Address - Country:US
Practice Address - Phone:616-840-8719
Practice Address - Fax:616-840-9637
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05407200208100000X
NY165156208100000X
MI4301102208208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0004405Medicaid
NJ070114Medicare ID - Type Unspecified
NJ0004405Medicaid
MIMI4327014Medicare UPIN