Provider Demographics
NPI:1447229620
Name:FENTON, KATHRYN ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:FENTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ELIZABETH
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:151 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2238
Mailing Address - Country:US
Mailing Address - Phone:937-382-6643
Mailing Address - Fax:937-382-6644
Practice Address - Street 1:151 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2238
Practice Address - Country:US
Practice Address - Phone:937-382-6643
Practice Address - Fax:937-382-6644
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH4190/T1094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0425980001Medicare NSC
OHFE0718431Medicare PIN
OHU32507Medicare UPIN