Basic Information
| Provider Information | |||||||||
| NPI: | 1114136959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENTON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | LUCIEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2015 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601873190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306688252 | ||||||||
| FaxNumber: | 6306688916 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601873190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306688250 | ||||||||
| FaxNumber: | 6306688916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MT185909 | PA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 036124435 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 313130004 | 01 | IL | MEDICARE | OTHER | 036124435 | 05 | IL | MEDICAID |