Active NPI
Michael Gregory Fenno, O.D.
- Optometrist
- Colville, WA
National Provider Identifier
1366439242
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 1708
- Practice address
- 102 S Oak St
Colville, WA 99114-2846 - Phone
- (509) 684-5278
- NPI assigned
- Oct 5, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 1708 | WA | Primary |
Addresses
Primary practice location
102 S Oak St
Colville, WA 99114-2846
Mailing address
102 S Oak St
Colville, WA 99114-2846
Phone (509) 684-5278
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2022960 | Medicaid | WA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1708 | WA | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1128470400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1634601600000",
"number": "1366439242",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "102 S OAK ST",
"city": "COLVILLE",
"state": "WA",
"postal_code": "991142846",
"telephone_number": "509-684-5278"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "102 S OAK ST",
"city": "COLVILLE",
"state": "WA",
"postal_code": "991142846",
"telephone_number": "509-684-5278"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FENNO",
"first_name": "MICHAEL",
"middle_name": "GREGORY",
"credential": "O.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-10-05",
"last_updated": "2021-10-19",
"certification_date": "2021-10-19",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "WA",
"license": "1708",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "2022960",
"state": "WA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Colville, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.