Provider Demographics
NPI:1740282086
Name:FELLNER, DENNIS R (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:R
Last Name:FELLNER
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 1:320 H ST
Mailing Address - Street 2:STE 4
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5834
Mailing Address - Country:US
Mailing Address - Phone:530-743-4453
Mailing Address - Fax:530-743-0427
Practice Address - Street 1:320 H ST
Practice Address - Street 2:STE 4
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5834
Practice Address - Country:US
Practice Address - Phone:530-743-4453
Practice Address - Fax:530-743-0427
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
CAOPT5143TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU37663Medicare UPIN
CASDO051430Medicare ID - Type Unspecified