Provider Demographics
NPI:1235457862
Name:DAVID A. FULLENKAMP,OD, PC
Entity Type:Organization
Organization Name:DAVID A. FULLENKAMP,OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:FULLENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-726-4210
Mailing Address - Street 1:1111 N MERIDIAN ST
Mailing Address - Street 2:P.O. BOX 1268
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-1024
Mailing Address - Country:US
Mailing Address - Phone:260-726-4210
Mailing Address - Fax:260-726-9347
Practice Address - Street 1:1111 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1024
Practice Address - Country:US
Practice Address - Phone:260-726-4210
Practice Address - Fax:260-726-9347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002167A332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100424160AMedicaid
IN0207200002OtherPTAN
263650Medicare PIN
INT69244Medicare UPIN