Provider Demographics
NPI:1891705208
Name:FETTERMAN, ALAN D (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:D
Last Name:FETTERMAN
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 1:325 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2779
Mailing Address - Country:US
Mailing Address - Phone:631-351-3434
Mailing Address - Fax:631-547-5349
Practice Address - Street 1:325 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2779
Practice Address - Country:US
Practice Address - Phone:631-351-3434
Practice Address - Fax:631-547-5349
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155848-2207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00985699Medicaid
NY00985699Medicaid