Provider Demographics
NPI:1912014507
Name:FETOUH, SALEH A (MD)
Entity Type:Individual
Prefix:MR
First Name:SALEH
Middle Name:A
Last Name:FETOUH
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 1:260 DEPEW AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214
Mailing Address - Country:US
Mailing Address - Phone:716-833-8413
Mailing Address - Fax:
Practice Address - Street 1:2828 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214
Practice Address - Country:US
Practice Address - Phone:716-838-1300
Practice Address - Fax:716-837-7725
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1320082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00610724Medicaid
075181Medicare ID - Type Unspecified
B71928Medicare UPIN