Provider Demographics
NPI:1699881052
Name:FETTERMAN, BRUCE L (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:FETTERMAN
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:PO BOX 2757
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38088-2757
Mailing Address - Country:US
Mailing Address - Phone:901-755-5300
Mailing Address - Fax:901-753-9659
Practice Address - Street 1:7600 WOLF RIVER BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1785
Practice Address - Country:US
Practice Address - Phone:901-755-5300
Practice Address - Fax:901-756-0196
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD29959207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4108473OtherBC
TN3818743Medicaid
AR97772OtherBC
TNP00238841OtherRR MEDICARE
AR97772OtherBC
TN3818743Medicaid