Provider Demographics
NPI:1306869177
Name:FETZ, ROBERT CRAIG (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CRAIG
Last Name:FETZ
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 1:101 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0556
Mailing Address - Country:US
Mailing Address - Phone:209-571-6622
Mailing Address - Fax:209-527-2069
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-577-4444
Practice Address - Fax:209-527-2069
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG331142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G331140Medicaid
CA00G331145Medicare PIN
CA00G331146Medicare PIN
CA300024662Medicare PIN
CA00G3311415Medicare PIN
CAA45432Medicare UPIN
CA00G3311413Medicare PIN
CA00G3311414Medicare PIN
CA00G3311410Medicare PIN
CA00G3311412Medicare PIN
CA00G331147Medicare PIN
CA00G331149Medicare PIN
CA00G331140Medicaid
CA00G331142Medicare PIN
CA00G331144Medicare PIN
CA00G331148Medicare PIN
CA00G331141Medicare PIN
CA00G331140Medicare PIN
CA00G3311411Medicare PIN