Provider Demographics
NPI:1851568133
Name:FETKO, C. NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:C. NICHOLAS
Middle Name:
Last Name:FETKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CARL
Other - Middle Name:NICHOLAS
Other - Last Name:FETKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:395 W 12TH AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:614-293-8315
Mailing Address - Fax:
Practice Address - Street 1:395 W 12TH AVE FL 4
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-293-8315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350942582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3004797Medicaid