Basic Information
| Provider Information | |||||||||
| NPI: | 1972708790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRS. PETERSON & JANNOTTA OPTOMETRISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4306 W CRYSTAL LAKE RD | ||||||||
| Address2: | STE D | ||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600504249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153857930 | ||||||||
| FaxNumber: | 8153859234 | ||||||||
| Practice Location | |||||||||
| Address1: | 4306 W CRYSTAL LAKE RD | ||||||||
| Address2: | STE D | ||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600504249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153857930 | ||||||||
| FaxNumber: | 8153859234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 01/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | JANNOTTA | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRACTIONER | ||||||||
| AuthorizedOfficialTelephone: | 8153857930 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 05632150 | 01 | IL | GROUP BC BS | OTHER |