Basic Information
| Provider Information | |||||||||
| NPI: | 1114091956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FECHO | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 NORWOOD PL | ||||||||
| Address2: | #N110 | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334316524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613923153 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3200 S UNIVERSITY DR | ||||||||
| Address2: | NSU THE EYE INSTITUTE SUITE 1402 | ||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542621402 | ||||||||
| FaxNumber: | 9542621818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC3581 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 620777400 | 05 | FL | MEDICAID |