Provider Demographics
NPI:1134119183
Name:FETCHICK, RICHARD J (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:FETCHICK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 HAMPTON WAY
Mailing Address - Street 2:
Mailing Address - City:SHAVANO PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2070
Mailing Address - Country:US
Mailing Address - Phone:210-410-2497
Mailing Address - Fax:
Practice Address - Street 1:422 HAMPTON WAY
Practice Address - Street 2:
Practice Address - City:SHAVANO PARK
Practice Address - State:TX
Practice Address - Zip Code:78249-2070
Practice Address - Country:US
Practice Address - Phone:210-410-2497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2131207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128682505Medicaid
B22691Medicare UPIN
TX128682505Medicaid