MEDICARE: DR. ROBERT DILLON FULLENWIDER OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046011435	IL

General Provider Information

NPI Number	:	1699386755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT DILLON FULLENWIDER OD

Provider Business Mailing Address
First Line	:	1412 DORIS AVE
Second Line	:
City	:	CAHOKIA
State	:	IL
Zip	:	62206-2234
Country	:	US
Telephone Number	:	618-980-3840
Fax Number	:

Provider Business Practice Location Address
First Line	:	823 9TH ST
Second Line	:
City	:	HIGHLAND
State	:	IL
Zip	:	62249-1521
Country	:	US
Telephone Number	:	618-654-9848
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2020
Last Update Date	:	08/12/2020

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