Provider Demographics
NPI:1356392377
Name:FAWCETT, WILLIAM R (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:FAWCETT
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 1:2500 E MARKET ST
Mailing Address - Street 2:P. O. BOX 597
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-2011
Mailing Address - Country:US
Mailing Address - Phone:574-722-5252
Mailing Address - Fax:574-722-3202
Practice Address - Street 1:2500 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947
Practice Address - Country:US
Practice Address - Phone:574-753-3583
Practice Address - Fax:574-722-2364
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001775A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100070660Medicaid
INP00366330Medicare PIN
IN247910AMedicare PIN
INP00714284Medicare PIN
IN084190FMedicare PIN
T34551Medicare UPIN
IN100070660Medicaid
IN452570KMedicare PIN
IN160450WMedicare PIN