Provider Demographics
NPI:1831207976
Name:FLETCHER, CHANTAL
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13922 BONNY KERRY DR
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-9508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 S CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-2907
Practice Address - Country:US
Practice Address - Phone:559-459-5700
Practice Address - Fax:559-459-6109
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A804480Medicaid
CAH70548Medicare UPIN
CA00A804480Medicare ID - Type Unspecified