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General NPI Number Information
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NPI Number | 1043297625
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Entity Type | Individual
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Provider Name | DAVID A FULLENKAMP O.D.
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Gender | Male
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Dates
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Enumeration Date | 12/27/2005
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Last Update Date | 11/24/2009
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Provider Practice Location Address
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Address Line | 1111 N MERIDIAN ST
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City | PORTLAND
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State | IN
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Zip | 47371-1024
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Country | US
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Telephone | 260-726-4210
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Fax | 260-726-9347
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Provider Business Mailing Address
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Address Line | PO BOX 1268
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City | PORTLAND
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State | IN
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Zip | 47371-3268
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Country | US
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Telephone | 260-726-4210
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Fax | 260-726-9347
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18002167A
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License Number State | IN
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