Healthcare Provider Details

I. General information

NPI: 1235457862
Provider Name (Legal Business Name): DAVID A. FULLENKAMP,OD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N MERIDIAN ST
PORTLAND IN
47371-1024
US

IV. Provider business mailing address

1111 N MERIDIAN ST P.O. BOX 1268
PORTLAND IN
47371-1024
US

V. Phone/Fax

Practice location:
  • Phone: 260-726-4210
  • Fax: 260-726-9347
Mailing address:
  • Phone: 260-726-4210
  • Fax: 260-726-9347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number18002167A
License Number StateIN

VIII. Authorized Official

Name: DR. DAVID A. FULLENKAMP
Title or Position: PRESIDENT
Credential: OD
Phone: 260-726-4210