Provider Demographics
NPI:1730249749
Name:FETTEROLF, DONALD EDWARD (MD, MBA)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:EDWARD
Last Name:FETTEROLF
Suffix:
Gender:M
Credentials:MD, MBA
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 246
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:PA
Mailing Address - Zip Code:15126-0246
Mailing Address - Country:US
Mailing Address - Phone:412-638-2891
Mailing Address - Fax:
Practice Address - Street 1:12 LAUREL HILL RD
Practice Address - Street 2:
Practice Address - City:MC DONALD
Practice Address - State:PA
Practice Address - Zip Code:15057-3503
Practice Address - Country:US
Practice Address - Phone:412-638-2891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD023825-E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD023825EOtherPA STATE LICENSE NUMBER
GA058175OtherGA STATE LICENSE NUMBER
GA058175OtherGA STATE LICENSE NUMBER