Provider Demographics
NPI:1710092499
Name:FATULA, DANIEL REMO (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:REMO
Last Name:FATULA
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 1:635 S BRADY ST
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1202
Mailing Address - Country:US
Mailing Address - Phone:814-503-4100
Mailing Address - Fax:814-503-4157
Practice Address - Street 1:635 S BRADY ST
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1202
Practice Address - Country:US
Practice Address - Phone:814-503-4100
Practice Address - Fax:814-503-4157
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001789152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024126310002Medicaid
PAV10696Medicare UPIN
PA104821Medicare ID - Type Unspecified