Provider Demographics
NPI:1851619811
Name:FITCH, PHILLIP NATHANIEL (OD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:NATHANIEL
Last Name:FITCH
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:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-0053
Mailing Address - Country:US
Mailing Address - Phone:641-780-5120
Mailing Address - Fax:
Practice Address - Street 1:1300 10TH AVE SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677
Practice Address - Country:US
Practice Address - Phone:319-483-5185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist