Healthcare Provider Details

I. General information

NPI: 1326023128
Provider Name (Legal Business Name): DOUGLAS R FETKENHOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/05/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LAC DE VILLE BLVD STE 250
ROCHESTER NY
14618
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 664
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-3271
  • Fax: 585-442-2949
Mailing address:
  • Phone: 585-275-3271
  • Fax: 585-442-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number235170
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number235170
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: