Provider Demographics
NPI:1104912682
Name:FEWTRELL, DEAN E (OD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:E
Last Name:FEWTRELL
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 1:311 PAJARO ST
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
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7793T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841325834Medicaid
CA0594810001Medicare NSC
CA1841325834Medicaid
CASD0077930Medicare PIN