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General NPI Number Information
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NPI Number | 1104899426
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Entity Type | Individual
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Provider Name | DAVID FENWICK
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Gender | Male
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Dates
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Enumeration Date | 02/08/2006
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Last Update Date | 04/04/2008
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Provider Practice Location Address
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Address Line | 424 N MAIN ST SUITE 4
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City | MIDDLEBURY
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State | IN
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Zip | 46540-8987
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Country | US
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Telephone | 574-825-3818
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Fax | 574-825-9497
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Provider Business Mailing Address
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Address Line | 424 N MAIN ST SUITE 4
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City | MIDDLEBURY
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State | IN
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Zip | 46540-8987
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Country | US
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Telephone | 574-825-3818
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Fax | 574-825-9497
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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 | 18002215B
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License Number State | IN
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