Provider Demographics
NPI:1912960626
Name:FENGEL, BRIAN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:FENGEL
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 1:933 MAMARONECK AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1662
Mailing Address - Country:US
Mailing Address - Phone:914-698-2182
Mailing Address - Fax:914-381-2676
Practice Address - Street 1:933 MAMARONECK AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-1662
Practice Address - Country:US
Practice Address - Phone:914-698-2182
Practice Address - Fax:914-381-2676
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004572-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400004914Medicare PIN
NYT49115Medicare UPIN