Basic Information
| Provider Information | |||||||||
| NPI: | 1114217536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPHTHALMOLOGY CONSULTANTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12990 MANCHESTER RD STE 2015006B | ||||||||
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| City: | DES PERES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631311881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149090633 | ||||||||
| FaxNumber: | 3145690864 | ||||||||
| Practice Location | |||||||||
| Address1: | 3248 GREEN MOUNT CROSSING DR | ||||||||
| Address2: | |||||||||
| City: | SHILOH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622697284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186229225 | ||||||||
| FaxNumber: | 6186246731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2011 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | DONAHOE | ||||||||
| AuthorizedOfficialFirstName: | MICAHEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3149090633 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.