MEDICARE: DAVID FENWICK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18002215B	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104899426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID FENWICK

Provider Business Mailing Address
First Line	:	424 N MAIN ST
Second Line	:	SUITE 4
City	:	MIDDLEBURY
State	:	IN
Zip	:	46540-8987
Country	:	US
Telephone Number	:	574-825-3818
Fax Number	:	574-825-9497

Provider Business Practice Location Address
First Line	:	424 N MAIN ST
Second Line	:	SUITE 4
City	:	MIDDLEBURY
State	:	IN
Zip	:	46540-8987
Country	:	US
Telephone Number	:	574-825-3818
Fax Number	:	574-825-9497

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	04/04/2008

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Directions to “ DAVID FENWICK ” Practice Location

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