Provider Demographics
NPI:1114128667
Name:ROGER D. FANNIN, OD, PSC
Entity Type:Organization
Organization Name:ROGER D. FANNIN, OD, PSC
Other - Org Name:FAMILY VISION HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:FANNIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-474-7833
Mailing Address - Street 1:313 S CAROL MALONE BLVD
Mailing Address - Street 2:PO BOX 485
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1357
Mailing Address - Country:US
Mailing Address - Phone:606-474-7833
Mailing Address - Fax:606-474-3563
Practice Address - Street 1:313 S CAROL MALONE BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1357
Practice Address - Country:US
Practice Address - Phone:606-474-7833
Practice Address - Fax:606-474-3563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1018DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77901023Medicaid
KYDA4435OtherRR MEDICARE
KY7669Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
KY77901023Medicaid