Healthcare Provider Details

I. General information

NPI: 1114128667
Provider Name (Legal Business Name): ROGER D. FANNIN, OD, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 S CAROL MALONE BLVD
GRAYSON KY
41143-1357
US

IV. Provider business mailing address

313 S CAROL MALONE BLVD PO BOX 485
GRAYSON KY
41143-1357
US

V. Phone/Fax

Practice location:
  • Phone: 606-474-7833
  • Fax: 606-474-3563
Mailing address:
  • Phone: 606-474-7833
  • Fax: 606-474-3563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1018DT
License Number StateKY

VIII. Authorized Official

Name: DR. ROGER D. FANNIN
Title or Position: PRESIDENT
Credential: OD
Phone: 606-474-7833