Provider Demographics
NPI:1770159337
Name:FORTKAMP, RANDY (OD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:FORTKAMP
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 1:3750 N TROY AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-9792
Mailing Address - Country:US
Mailing Address - Phone:260-251-5533
Mailing Address - Fax:
Practice Address - Street 1:711 N RIVER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2672
Practice Address - Country:US
Practice Address - Phone:765-664-9637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004260A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist