Healthcare Provider Details

I. General information

NPI: 1053404780
Provider Name (Legal Business Name): JOHN FRANCIS COUILLARD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 E. WASHINGTON ST. SUITE 1D
BLOOMINGTON IL
61701-4365
US

IV. Provider business mailing address

2103 E. WASHINGTON ST. SUITE 1D
BLOOMINGTON IL
61701-4365
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-2277
  • Fax: 309-663-6472
Mailing address:
  • Phone: 309-662-2277
  • Fax: 309-663-6472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: