Provider Demographics
NPI:1902971419
Name:FUGATE, J.E.B. (OD)
Entity Type:Individual
Prefix:DR
First Name:J.E.B.
Middle Name:
Last Name:FUGATE
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 1:825 FISHBURN RD
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2015
Mailing Address - Country:US
Mailing Address - Phone:717-533-5200
Mailing Address - Fax:717-533-2606
Practice Address - Street 1:825 FISHBURN RD
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2015
Practice Address - Country:US
Practice Address - Phone:717-533-5200
Practice Address - Fax:717-533-2606
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAID001997161OtherHIGHMARK BS
PA102057079002Medicaid
PAP00733848OtherRAILROAD MEDICARE
PA558206OtherBLUE SHIELD
PAP00733848OtherRAILROAD MEDICARE
PA558206OtherBLUE SHIELD
PA0287340001Medicare NSC
PAP00334618Medicare PIN