Provider Demographics
NPI:1841296985
Name:FLEMING, RODNEY G
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:G
Last Name:FLEMING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-5280
Mailing Address - Country:US
Mailing Address - Phone:217-234-3648
Mailing Address - Fax:217-235-0356
Practice Address - Street 1:1601 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-5280
Practice Address - Country:US
Practice Address - Phone:217-234-3648
Practice Address - Fax:217-235-0356
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL466838152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL004008OtherHEALTH ALLIANCE
IL118513OtherHEALTH LINK
IL225970OtherPERSONAL CARE
IL466838OtherBLUE CROSS/BLUE SHIELD
IL371015473OtherOTHER INS. TAX ID
IL118513OtherHEALTH LINK
IL371015473OtherOTHER INS. TAX ID
ILT35422Medicare UPIN
IL410046319Medicare PIN