Provider Demographics
NPI:1093790941
Name:FENNEWALD, WILFRED JAMES (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:WILFRED
Middle Name:JAMES
Last Name:FENNEWALD
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:MR
Other - First Name:W JAMES
Other - Middle Name:
Other - Last Name:FENNEWALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2737 NAVARRE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3276
Mailing Address - Country:US
Mailing Address - Phone:419-693-3376
Mailing Address - Fax:419-693-7519
Practice Address - Street 1:2737 NAVARRE AVE STE 204
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3276
Practice Address - Country:US
Practice Address - Phone:419-693-3376
Practice Address - Fax:419-693-7519
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC2077156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH363492OtherNVA
OHOH2077OtherEYEMED
OH0511637Medicaid
OH31106091100OtherBWC
OH000000155056OtherANTHEM
OH10251OtherPARAMOUNT HEALTH CARE
OH311060911001OtherMEDICAL MUTUAL
OH15295OtherSPECTERA
OH0511637Medicaid