Provider Demographics
NPI:1083734420
Name:FATULA FAMILY EYECARE
Entity Type:Organization
Organization Name:FATULA FAMILY EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:REMO
Authorized Official - Last Name:FATULA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-371-8210
Mailing Address - Street 1:111 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1722
Mailing Address - Country:US
Mailing Address - Phone:814-371-8210
Mailing Address - Fax:814-834-1243
Practice Address - Street 1:1102 MILLION DOLLAR HWY
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-2728
Practice Address - Country:US
Practice Address - Phone:814-781-1064
Practice Address - Fax:814-834-1243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001789152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104821Medicare ID - Type Unspecified
PAV10696Medicare UPIN