MEDICARE: DALE FREDERICK FATH OD

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	18001634A	IN

General Provider Information

NPI Number	:	1750358347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE FREDERICK FATH OD

Provider Business Mailing Address
First Line	:	7750 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804
Country	:	US
Telephone Number	:	260-459-9595
Fax Number	:	260-459-9494

Provider Business Practice Location Address
First Line	:	7750 W JEFFERSON BLVD
Second Line	:
City	:	FT WAYNE
State	:	IN
Zip	:	46804
Country	:	US
Telephone Number	:	260-459-9595
Fax Number	:	260-459-9494

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

Provider Enumeration Date	:	03/02/2006
Last Update Date	:	07/09/2007

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