Provider Demographics
NPI:1992843783
Name:FETCH, DENNIS IVAN (OD,PA)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:IVAN
Last Name:FETCH
Suffix:
Gender:M
Credentials:OD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 N FEDERAL HWY
Mailing Address - Street 2:SUITE #4
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3253
Mailing Address - Country:US
Mailing Address - Phone:954-491-6663
Mailing Address - Fax:954-491-6697
Practice Address - Street 1:5200 N FEDERAL HWY
Practice Address - Street 2:SUITE #4
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3253
Practice Address - Country:US
Practice Address - Phone:954-491-6663
Practice Address - Fax:954-491-6697
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1081152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650601816OtherTAX ID
FL650601816OtherTAX ID