Provider Demographics
NPI:1891769857
Name:FELLMETH, WAYNE G (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:G
Last Name:FELLMETH
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 1:6 SAND HILL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-4946
Mailing Address - Country:US
Mailing Address - Phone:908-782-6700
Mailing Address - Fax:
Practice Address - Street 1:6 SAND HILL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-4946
Practice Address - Country:US
Practice Address - Phone:908-782-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA44346208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1132300Medicaid
NJE73079Medicare UPIN
NJ1132300Medicaid