1962988550 NPI number — DR. ELIZABETH CLARA FAHY OD

Table of content: LISSA A WICK (NPI 1649850389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962988550 NPI number — DR. ELIZABETH CLARA FAHY OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAHY
Provider First Name:
ELIZABETH
Provider Middle Name:
CLARA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1962988550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CMR 411 BOX 2164
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09112-0022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-548-5885
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US ARMY HEALTH CLINIC VILSECK - OPTOMETRY
Provider Second Line Business Practice Location Address:
BUILDING 260
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-590-2300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2018

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:  OPT.006641 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: H717470 . This is a "MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0349463 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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