Provider Demographics
NPI:1073599429
Name:FEWELL, R. MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:R.
Middle Name:MICHAEL
Last Name:FEWELL
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 1:3421 S LAFOUNTAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3801
Mailing Address - Country:US
Mailing Address - Phone:765-455-0404
Mailing Address - Fax:765-455-1765
Practice Address - Street 1:3421 S LAFOUNTAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3801
Practice Address - Country:US
Practice Address - Phone:765-455-0404
Practice Address - Fax:765-455-1765
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001678B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN363100Medicare ID - Type Unspecified
INT34695Medicare UPIN