MEDICARE: DR. JEFFREY SCOTT PORTER O.D.

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	046.008991	IL

General Provider Information

NPI Number	:	1982747507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY SCOTT PORTER O.D.

Provider Business Mailing Address
First Line	:	3912 VALLEY VIEW RD
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60012-2104
Country	:	US
Telephone Number	:	847-323-8501
Fax Number	:	312-781-3527

Provider Business Practice Location Address
First Line	:	1205 S IL ROUTE 31
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-8213
Country	:	US
Telephone Number	:	815-477-4053
Fax Number	:	815-477-4302

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

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	08/20/2020

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