Basic Information
| Provider Information | |||||||||
| NPI: | 1740236090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 MALTESE DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453424774 | ||||||||
| FaxNumber: | 8458187555 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 MALTESE DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453424774 | ||||||||
| FaxNumber: | 8458187555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 02/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 177652 1 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 177652 1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 01144256 | 05 | NY | MEDICAID | 1144256 | 05 | NY | MEDICAID |