Provider Demographics
NPI:1700297058
Name:FATULA FAMILY EYE CARE PLLC
Entity Type:Organization
Organization Name:FATULA FAMILY EYE CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:FATULA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-913-3006
Mailing Address - Street 1:220 SYLVAN HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-5868
Mailing Address - Country:US
Mailing Address - Phone:814-913-3006
Mailing Address - Fax:814-371-2713
Practice Address - Street 1:20 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-3842
Practice Address - Country:US
Practice Address - Phone:814-913-3006
Practice Address - Fax:814-371-2713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001789152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024126310002Medicaid
PA104821Medicare PIN