Healthcare Provider Details

I. General information

NPI: 1801881040
Provider Name (Legal Business Name): JOHN C FETZER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2191 E JOHNSON AVE
PENSACOLA FL
32514-6029
US

IV. Provider business mailing address

2191 E JOHNSON AVE
PENSACOLA FL
32514-6029
US

V. Phone/Fax

Practice location:
  • Phone: 850-494-3917
  • Fax: 850-494-3960
Mailing address:
  • Phone: 850-494-3917
  • Fax: 850-494-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME48794
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: