Provider Demographics
NPI:1861517682
Name:FEWELL EYE CLINIC
Entity type:Organization
Organization Name:FEWELL EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-455-0404
Mailing Address - Street 1:PO BOX 2767
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46904-2767
Mailing Address - Country:US
Mailing Address - Phone:765-455-0404
Mailing Address - Fax:765-455-1765
Practice Address - Street 1:3421 S LAFOUNTAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3852
Practice Address - Country:US
Practice Address - Phone:765-455-0404
Practice Address - Fax:765-455-1765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001678B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN363100Medicare ID - Type Unspecified
IN1073599429Medicare UPIN
IN0394240001Medicare NSC