Provider Demographics
NPI:1801881040
Name:FETZER, JOHN C (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:FETZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2191 E JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6029
Mailing Address - Country:US
Mailing Address - Phone:850-494-3917
Mailing Address - Fax:850-494-3960
Practice Address - Street 1:2191 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6029
Practice Address - Country:US
Practice Address - Phone:850-494-3917
Practice Address - Fax:850-494-3960
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME487942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044224100Medicaid
FL17665XMedicare ID - Type Unspecified
FL044224100Medicaid