Individual
DAVID A FULLENKAMP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
1111 N MERIDIAN ST, PORTLAND, IN 47371-1024
(260) 726-4210
(260) 726-9347
Mailing address
PO BOX 1268, PORTLAND, IN 47371-3268
(260) 726-4210
(260) 726-9347
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
18002167A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100147120
—
IN
05
—
2090544
—
OH
Enumeration date
12/27/2005
Last updated
11/24/2009
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