1043297625 NPI number — DAVID A FULLENKAMP O.D.

Table of content: DAVID A FULLENKAMP O.D. (NPI 1043297625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043297625 NPI number — DAVID A FULLENKAMP O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLENKAMP
Provider First Name:
DAVID
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043297625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1268
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47371-3268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-726-4210
Provider Business Mailing Address Fax Number:
260-726-9347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 N MERIDIAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47371-1024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-726-4210
Provider Business Practice Location Address Fax Number:
260-726-9347
Provider Enumeration Date:
12/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18002167A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100147120 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2090544 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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