Basic Information
| Provider Information | |||||||||
| NPI: | 1861469918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLLOCK | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
| FaxNumber: | 3147414947 | ||||||||
| Practice Location | |||||||||
| Address1: | 5694 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631294243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148464222 | ||||||||
| FaxNumber: | 8004326004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TO2246 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 108710 | 01 | BLUE CROSS BLUE SHIELD MO | OTHER | 12453 | 01 | OPTICARE MEDICARE COMPLET | OTHER | 340370 | 01 | HEALTHLINK | OTHER | 410048091 | 01 | IL | RR MEDICARE | OTHER | 5217 | 01 | DAVIS VISION | OTHER | T92390 | 01 | MERCY HEALTH PLAN | OTHER | P00305305 | 01 | MO | RR MEDICARE | OTHER | 110977 | 01 | EYEMED | OTHER | 310754627 | 05 | MO | MEDICAID | 4197 | 01 | MO | HEALTHCARE USA | OTHER | 22-00135 | 01 | UNITED HEALTHCARE | OTHER |