Organization
DAVID A. FULLENKAMP,OD, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DAVID A. FULLENKAMP OD (PRESIDENT)
(260) 726-4210
Entity
Organization
Contact information
Practice address
1111 N MERIDIAN ST, PORTLAND, IN 47371-1024
(260) 726-4210
(260) 726-9347
Mailing address
1111 N MERIDIAN ST, P.O. BOX 1268, PORTLAND, IN 47371-1024
(260) 726-4210
(260) 726-9347
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
18002167A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0207200002
PTAN
IN
05
—
100424160A
—
IN
Enumeration date
05/06/2010
Last updated
05/06/2010
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