Provider Demographics
NPI:1457397499
Name:JOHN A FETCHERO JR D O P A
Entity Type:Organization
Organization Name:JOHN A FETCHERO JR D O P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:FETCHERO
Authorized Official - Suffix:JR
Authorized Official - Credentials:D O
Authorized Official - Phone:904-278-3820
Mailing Address - Street 1:2862 COUNTRY CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5728
Mailing Address - Country:US
Mailing Address - Phone:904-278-3820
Mailing Address - Fax:904-278-3849
Practice Address - Street 1:1542 KINGSLEY AVE STE 140
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4547
Practice Address - Country:US
Practice Address - Phone:904-278-3820
Practice Address - Fax:904-278-3849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048447400Medicaid
FLDL670AMedicare PIN