Provider Demographics
NPI:1407857766
Name:FANNIN, ROGER D (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
Last Name:FANNIN
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 1:313 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1018DT332H00000X
KY1018DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010189Medicaid
KY5965025OtherAETNA
KY45775780OtherEPSDT
KY000000048519OtherANTHEM
611071677OtherFEDERAL TAX ID
KYP00059060OtherRR MEDICARE PTAN
2272760OtherFIRST HEALTH INS. CO
KY5965025OtherAETNA
KYT54695Medicare UPIN
KY0766901Medicare ID - Type Unspecified