Basic Information
| Provider Information | |||||||||
| NPI: | 1033192133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLEMING | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9628 CAMPO RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRING VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919771245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194639318 | ||||||||
| FaxNumber: | 6194639640 | ||||||||
| Practice Location | |||||||||
| Address1: | 9628 CAMPO RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRING VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919771245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194639318 | ||||||||
| FaxNumber: | 6194639640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 10/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT 8461 T | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 4079022 | 05 | CA | MEDICAID |