Provider Demographics
NPI:1659303287
Name:FETTER, JOHN EDGAR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDGAR
Last Name:FETTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 FANNIN ST
Mailing Address - Street 2:SUITE B452
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-3620
Mailing Address - Fax:713-790-2082
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:SUITE B452
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-3620
Practice Address - Fax:713-790-2082
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56823207RP1001X
TXN3028208600000X, 208G00000X, 2086S0102X
MN41164208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32494500Medicaid
TX8DY860OtherBLUE CROSS BLUE SHIELD
TXP00759962OtherMEDICARE RAILROAD
TXP01254102OtherMEDICARE RR
MN202518300Medicaid
TX203934901Medicaid
TX203934902Medicaid
TX203934903Medicaid
TXP01030486OtherRR MEDICARE
TX8W4777OtherBLUE CROSS BLUE SHIELD
WI32494500Medicaid
TXP01254102OtherMEDICARE RR
TX8DY860OtherBLUE CROSS BLUE SHIELD
G46990Medicare UPIN
WI32494500Medicaid
TX203934903Medicaid