Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0801X | Contact Lens Fitter | SC2077 | OH |
Y | 156FX1800X | Optician | SC2077 | OH |
NPI | 1093790941 |
---|---|
Provider Name | Mr. Wilfred James Fennewald |
First Address | Oregon, OH 43616-3276 |
Second Address | Oregon, OH 43616-3276 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2005 |
Last Update Date | 28/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000155056 | ANTHEM (01) | OH |
0511637 | (05) | OH |
10251 | PARAMOUNT HEALTH CARE (01) | OH |
15295 | SPECTERA (01) | OH |
31106091100 | BWC (01) | OH |
311060911001 | MEDICAL MUTUAL (01) | OH |
363492 | NVA (01) | OH |
OH2077 | EYEMED (01) | OH |