Provider Demographics
NPI:1902868383
Name:FETTERMAN, CRAIG M (DO)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:M
Last Name:FETTERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-4948
Mailing Address - Country:US
Mailing Address - Phone:716-649-0887
Mailing Address - Fax:716-646-4611
Practice Address - Street 1:2950 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1304
Practice Address - Country:US
Practice Address - Phone:716-634-8800
Practice Address - Fax:716-634-8987
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230757207R00000X
NY230757-1208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0412489OtherINDEPENDENT HEALTH
NY000527760001OtherBC/BS
NY0026827302OtherUNIVERA
NY02533062Medicaid
NY041006000116OtherFIDELIS
I10628Medicare UPIN
NYRB2482Medicare PIN