Provider Demographics
NPI:1043297625
Name:FULLENKAMP, DAVID A (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:FULLENKAMP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-3268
Mailing Address - Country:US
Mailing Address - Phone:260-726-4210
Mailing Address - Fax:260-726-9347
Practice Address - Street 1:1111 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1024
Practice Address - Country:US
Practice Address - Phone:260-726-4210
Practice Address - Fax:260-726-9347
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002167A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100147120Medicaid
OH2090544Medicaid
IN100147120Medicaid
OH2090544Medicaid
IN402810CMedicare PIN
IN410032872Medicare PIN