Provider Demographics
NPI:1740208388
Name:FENN, DON J (OD)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:J
Last Name:FENN
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 1:964 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206
Mailing Address - Country:US
Mailing Address - Phone:615-262-4830
Mailing Address - Fax:615-226-8527
Practice Address - Street 1:964 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37206
Practice Address - Country:US
Practice Address - Phone:615-262-4830
Practice Address - Fax:615-226-8527
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3594948Medicaid
TN52511OtherTENN CORE SELECT
T61217Medicare UPIN
3594948Medicare ID - Type Unspecified