MEDICARE: JAVIER RAMIRO RODRIGUEZ OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046.011137	IL

General Provider Information

NPI Number	:	1275056236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAVIER RAMIRO RODRIGUEZ OD

Provider Business Mailing Address
First Line	:	1591 CARLEMONT DR APT B
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-2742
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 N STATE ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2239
Country	:	US
Telephone Number	:	815-568-6508
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2017
Last Update Date	:	03/17/2018

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