Provider Demographics
NPI:1942256037
Name:BYRON M FENNEMA O.D. INC
Entity Type:Organization
Organization Name:BYRON M FENNEMA O.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:MUNEHIRO
Authorized Official - Last Name:FENNEMA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-997-1091
Mailing Address - Street 1:1234 W CHAPMAN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2862
Mailing Address - Country:US
Mailing Address - Phone:714-997-1091
Mailing Address - Fax:714-547-8279
Practice Address - Street 1:1234 W CHAPMAN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2862
Practice Address - Country:US
Practice Address - Phone:714-997-1091
Practice Address - Fax:714-547-8279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5522TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055220Medicaid
CAT70036Medicare UPIN
CASD0055220Medicaid