Provider Demographics
NPI:1144280934
Name:FENTON, MARK DWAIN (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DWAIN
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 1:375 INDIAN RIPPLE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177
Mailing Address - Country:US
Mailing Address - Phone:937-383-2410
Mailing Address - Fax:
Practice Address - Street 1:8548 BEECHMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-4708
Practice Address - Country:US
Practice Address - Phone:513-474-0122
Practice Address - Fax:513-474-1376
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U06126Medicare UPIN
OHFE0679981Medicare ID - Type Unspecified