Provider Demographics
NPI:1982389433
Name:FAY, AUSTIN EMORY (OD)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:EMORY
Last Name:FAY
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 1:6204 MACKENZIE PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6748
Mailing Address - Country:US
Mailing Address - Phone:217-206-5453
Mailing Address - Fax:
Practice Address - Street 1:161 HAMPTON POINT DR STE 3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3058
Practice Address - Country:US
Practice Address - Phone:904-204-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6252152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist