Provider Demographics
NPI:1316983950
Name:FEHLAUER, TIMOTHY JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:FEHLAUER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:TIM
Other - Middle Name:JAMES
Other - Last Name:FEHLAUER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:116 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4224
Mailing Address - Country:US
Mailing Address - Phone:307-675-2020
Mailing Address - Fax:307-674-8042
Practice Address - Street 1:116 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4224
Practice Address - Country:US
Practice Address - Phone:307-675-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY286T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119284100Medicaid
WY9925Medicare PIN
WY119284100Medicaid