Provider Demographics
NPI:1699932863
Name:MARK D & KATHRYN E FENTON
Entity type:Organization
Organization Name:MARK D & KATHRYN E FENTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:E
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-382-6643
Mailing Address - Street 1:151 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2238
Mailing Address - Country:US
Mailing Address - Phone:937-382-6643
Mailing Address - Fax:937-382-6644
Practice Address - Street 1:151 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2238
Practice Address - Country:US
Practice Address - Phone:937-382-6643
Practice Address - Fax:937-382-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4190332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU32507Medicare UPIN
OH0425980001Medicare NSC