Healthcare Provider Details

I. General information

NPI: 1093832008
Provider Name (Legal Business Name): J. MICETICH, OD & ASSOCIATES FAMILY EYE CARE CENTER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E NORTH ST
COAL CITY IL
60416-1087
US

IV. Provider business mailing address

2920 GATEWAY GORGE
MORRIS IL
60450-9771
US

V. Phone/Fax

Practice location:
  • Phone: 815-634-4825
  • Fax:
Mailing address:
  • Phone: 815-634-4825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-008925
License Number StateIL

VIII. Authorized Official

Name: DR. JONATHAN EDWARD MICETICH
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 815-634-4825