Provider Demographics
NPI:1104899426
Name:FENWICK, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FENWICK
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 1:424 N MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-8987
Mailing Address - Country:US
Mailing Address - Phone:574-825-3818
Mailing Address - Fax:574-825-9497
Practice Address - Street 1:424 N MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-8987
Practice Address - Country:US
Practice Address - Phone:574-825-3818
Practice Address - Fax:574-825-9497
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002215B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325370Medicaid
IN229280AMedicare PIN
IN100325370Medicaid