Healthcare Provider Details

I. General information

NPI: 1750358347
Provider Name (Legal Business Name): DALE FREDERICK FATH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7750 W JEFFERSON BLVD
FT WAYNE IN
46804
US

IV. Provider business mailing address

7750 W JEFFERSON BLVD
FORT WAYNE IN
46804
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-9595
  • Fax: 260-459-9494
Mailing address:
  • Phone: 260-459-9595
  • Fax: 260-459-9494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001634A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: