Provider Demographics
NPI:1841249679
Name:FENTON, RICHARD A (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:FENTON
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 1:61 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45354
Mailing Address - Country:US
Mailing Address - Phone:937-884-7891
Mailing Address - Fax:
Practice Address - Street 1:1679 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-3336
Practice Address - Country:US
Practice Address - Phone:937-258-1515
Practice Address - Fax:937-258-9790
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH4100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0769511Medicaid
OH0899425Medicare PIN
OHU06526Medicare UPIN
OH0769511Medicaid