Provider Demographics
NPI:1215920442
Name:FENTON, ELVIN W (OD)
Entity type:Individual
Prefix:MR
First Name:ELVIN
Middle Name:W
Last Name:FENTON
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:751 MID CITIES BLVD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2748
Practice Address - Country:US
Practice Address - Phone:817-656-2020
Practice Address - Fax:817-656-5908
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0193336-01Medicaid
AR134244722Medicaid
AR97883OtherAR BCBS PROVIDER NUMBER
TX83324EOtherBCBS PROVIDER
TX83324EOtherBCBS PROVIDER
AR97883OtherAR BCBS PROVIDER NUMBER
TXU63005Medicare UPIN