Provider Demographics
NPI:1346479284
Name:DAVID A. FULLENKAMP, O.D., P.C.
Entity Type:Organization
Organization Name:DAVID A. FULLENKAMP, O.D., P.C.
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:260-726-5161
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:260-726-5161
Mailing Address - Fax:
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:260-726-5161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002167A152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100424160AMedicaid
263650Medicare PIN
INT69244Medicare UPIN
0207200002Medicare NSC