Healthcare Provider Details

I. General information

NPI: 1861124943
Provider Name (Legal Business Name): BEAU JAMES FENNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

IV. Provider business mailing address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

V. Phone/Fax

Practice location:
  • Phone: 319-356-3705
  • Fax: 319-353-6030
Mailing address:
  • Phone: 319-356-3705
  • Fax: 319-353-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD-49725
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD-49725
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: