Healthcare Provider Details

I. General information

NPI: 1740687912
Provider Name (Legal Business Name): PHILLIP N FITCH OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W 1ST ST
MONTICELLO IA
52310-1519
US

IV. Provider business mailing address

108 W 1ST ST
MONTICELLO IA
52310-1519
US

V. Phone/Fax

Practice location:
  • Phone: 319-465-5114
  • Fax: 319-465-5523
Mailing address:
  • Phone: 319-465-5114
  • Fax: 319-465-5523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002491
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number002491
License Number StateIA

VIII. Authorized Official

Name: PHILLIP N FITCH
Title or Position: OWNER
Credential: ODQ
Phone: 319-465-5114