Provider Demographics
NPI:1043385198
Name:FRECKER, MELVIN L (OD)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:L
Last Name:FRECKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-0479
Mailing Address - Country:US
Mailing Address - Phone:765-664-7647
Mailing Address - Fax:765-668-1495
Practice Address - Street 1:1402 W SPENCER AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3413
Practice Address - Country:US
Practice Address - Phone:765-664-7647
Practice Address - Fax:765-668-1495
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002023B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100151660AMedicaid
IN100151660AMedicaid
IN293330Medicare ID - Type Unspecified