Provider Demographics
NPI:1174722946
Name:FETTERS, CLIFFORD W (MD)
Entity type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:W
Last Name:FETTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11900 N PENNSYLVANIA ST
Mailing Address - Street 2:STE 200
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-4694
Mailing Address - Country:US
Mailing Address - Phone:317-663-7123
Mailing Address - Fax:317-587-0496
Practice Address - Street 1:11900 N PENNSYLVANIA ST
Practice Address - Street 2:STE 200
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4694
Practice Address - Country:US
Practice Address - Phone:317-663-7123
Practice Address - Fax:317-587-0496
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034557A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100332730Medicaid
IN000000532027OtherANTHEM
D95260Medicare UPIN
IN898190M12Medicare PIN