Provider Demographics
NPI:1588955439
Name:FETTER, MAYA DAGHER (MD)
Entity type:Individual
Prefix:DR
First Name:MAYA
Middle Name:DAGHER
Last Name:FETTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:704-495-6334
Mailing Address - Fax:704-817-7219
Practice Address - Street 1:16817 MARVIN ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-495-6036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00704207R00000X
NC173258207R00000X
SC38029207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1588955439Medicaid
SCNC2194Medicaid
SCNC2194Medicaid
NCNCK073BMedicare PIN