Basic Information
| Provider Information | |||||||||
| NPI: | 1114075645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EILENFELDT | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MIKULECKY | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8309 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616152170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096939540 | ||||||||
| FaxNumber: | 3096939542 | ||||||||
| Practice Location | |||||||||
| Address1: | 1265 N HENDERSON ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093437799 | ||||||||
| FaxNumber: | 3093437934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046-008618 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046008618 | 05 | IL | MEDICAID |