Provider Demographics
NPI:1306839642
Name:FANELLI, GREGORY L (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:FANELLI
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 1:151 FRIES MILL RD
Mailing Address - Street 2:UNIVERSITY EXECUTIVE CAMPUS, SUITE 306
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2016
Mailing Address - Country:US
Mailing Address - Phone:856-227-3340
Mailing Address - Fax:856-227-7226
Practice Address - Street 1:151 FRIES MILL RD
Practice Address - Street 2:UNIVERSITY EXECUTIVE CAMPUS, SUITE 306
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2016
Practice Address - Country:US
Practice Address - Phone:856-227-3340
Practice Address - Fax:856-227-7226
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ3807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJFA135947Medicare ID - Type Unspecified
NJU24919Medicare UPIN