Provider Demographics
NPI:1841325834
Name:DEAN E FEWTRELL OD A PROFESSIONAL OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:DEAN E FEWTRELL OD A PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:FEWTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:831-424-6201
Mailing Address - Street 1:311 PAJARO STREET
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-3421
Mailing Address - Country:US
Mailing Address - Phone:831-424-6201
Mailing Address - Fax:831-757-4509
Practice Address - Street 1:311 PAJARO ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3421
Practice Address - Country:US
Practice Address - Phone:831-424-6201
Practice Address - Fax:831-757-4509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7793T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841325834Medicaid
CAT90802Medicare UPIN
CA0594810001Medicare NSC
CASD0077930Medicare PIN