Provider Demographics
NPI:1710048939
Name:FENNEMA, ERIC MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MATTHEW
Last Name:FENNEMA
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 1:29950 HAUN RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6526
Mailing Address - Country:US
Mailing Address - Phone:951-679-0545
Mailing Address - Fax:951-679-6154
Practice Address - Street 1:29950 HAUN RD
Practice Address - Street 2:SUITE 206
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-6526
Practice Address - Country:US
Practice Address - Phone:951-679-0545
Practice Address - Fax:951-679-6154
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8225TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0082250Medicare ID - Type Unspecified
CAU47231Medicare UPIN
CA6263350001Medicare NSC