Provider Demographics
NPI:1750392668
Name:FETHEROLF, EDWARD (MD PA)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:FETHEROLF
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PLACIDA RD
Mailing Address - Street 2:B2
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223
Mailing Address - Country:US
Mailing Address - Phone:941-475-5500
Mailing Address - Fax:941-475-7274
Practice Address - Street 1:1500 PLACIDA RD
Practice Address - Street 2:B2
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223
Practice Address - Country:US
Practice Address - Phone:941-475-5500
Practice Address - Fax:941-475-7274
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30596207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374759000Medicaid
D56921Medicare UPIN
FL58297AMedicare PIN