Provider Demographics
NPI:1972548386
Name:FAIT, ROBERT L (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:FAIT
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 630
Mailing Address - Street 2:309 MCHENRY ST
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-0630
Mailing Address - Country:US
Mailing Address - Phone:262-763-0117
Mailing Address - Fax:262-763-0119
Practice Address - Street 1:309 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-2123
Practice Address - Country:US
Practice Address - Phone:262-763-0117
Practice Address - Fax:262-763-0119
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1332035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38569200Medicaid
WI38569200Medicaid
WI000247545Medicare ID - Type Unspecified