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General NPI Number Information
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NPI Number | 1114128667
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Entity Type | Organization
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Legal Business Name | ROGER D. FANNIN, OD, PSC
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 04/14/2023
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Provider Practice Location Address
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Address Line | 313 S CAROL MALONE BLVD
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City | GRAYSON
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State | KY
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Zip | 41143-1357
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Country | US
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Telephone | 606-474-7833
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Fax | 606-474-3563
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Provider Business Mailing Address
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Address Line | 313 S CAROL MALONE BLVD PO BOX 485
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City | GRAYSON
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State | KY
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Zip | 41143-1357
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Country | US
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Telephone | 606-474-7833
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Fax | 606-474-3563
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROGER D. FANNIN
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Credential | OD
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Telephone | 606-474-7833
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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 | 1018DT
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License Number State | KY
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