Provider Demographics
NPI:1194884544
Name:FLETCHER, JOHN R (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 S AVENUE A #3
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7174
Mailing Address - Country:US
Mailing Address - Phone:928-344-3250
Mailing Address - Fax:928-344-3253
Practice Address - Street 1:2503 S AVENUE A #3
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7174
Practice Address - Country:US
Practice Address - Phone:928-344-3250
Practice Address - Fax:928-344-3253
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28797208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ543448Medicaid
AZAZ0877760OtherBCBS
AZZ64291Medicare ID - Type Unspecified
AZ543448Medicaid