Provider Demographics
NPI:1578657094
Name:FETHKE, KATHRYN M (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:M
Last Name:FETHKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:999 N. CURTIS
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706
Mailing Address - Country:US
Mailing Address - Phone:208-373-1200
Mailing Address - Fax:208-373-1216
Practice Address - Street 1:999 N. CURTIS
Practice Address - Street 2:SUITE 205
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-373-1200
Practice Address - Fax:208-373-1216
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM7977207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010029522OtherREGENCE BLUE SHIELD OF ID
ID37879OtherBLUE CROSS OF IDAHO
ID37879OtherBLUE CROSS OF IDAHO
IDH21191Medicare UPIN