Provider Demographics
NPI:1831153881
Name:FANELLI, JEFFREY M (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:FANELLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1412 ARROYO SECO DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008
Mailing Address - Country:US
Mailing Address - Phone:408-559-4517
Mailing Address - Fax:
Practice Address - Street 1:1817 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95725
Practice Address - Country:US
Practice Address - Phone:408-264-1555
Practice Address - Fax:408-264-1562
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 8168 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T10657Medicare UPIN
S00081680Medicare ID - Type Unspecified