Organization
DAVID A. FULLENKAMP, O.D., P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DAVID A. FULLENKAMP O.D. (PRESIDENT)
(260) 726-5161
Entity
Organization
Contact information
Practice address
1111 N MERIDIAN ST, PORTLAND, IN 47371-1024
(260) 726-5161
Mailing address
1111 N MERIDIAN ST, P.O. BOX 1268, PORTLAND, IN 47371-1024
(260) 726-5161
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
18002167A
IN
332H00000X
Eyewear Supplier
18002167A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100424160A
—
IN
Enumeration date
07/14/2009
Last updated
05/13/2010
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