Basic Information
| Provider Information | |||||||||
| NPI: | 1548381635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | A & M OPTICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 591 SOUTH EASTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600984631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153380107 | ||||||||
| FaxNumber: | 8153385104 | ||||||||
| Practice Location | |||||||||
| Address1: | 591 SOUTH EASTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600984631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153380107 | ||||||||
| FaxNumber: | 8153385104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | ATKINSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 8153380107 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 05632271 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 1548381635 | 01 | OFFICE NPI | OTHER |