Individual
DR. ROGER D. FANNIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
313 S CAROL MALONE BLVD, GRAYSON, KY 41143-1357
(606) 474-7833
(606) 474-3563
Mailing address
313 S CAROL MALONE BLVD, PO BOX 485, GRAYSON, KY 41143-1357
(606) 474-7833
(606) 474-3563
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1018DT
KY
332H00000X
Eyewear Supplier
KY1018DT
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000048519
ANTHEM
KY
01
—
2272760
FIRST HEALTH INS. CO
—
01
—
45775780
EPSDT
KY
01
—
5965025
AETNA
KY
01
—
611071677
FEDERAL TAX ID
—
05
—
77010189
—
KY
01
—
P00059060
RR MEDICARE PTAN
KY
Enumeration date
08/09/2005
Last updated
04/14/2023
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