Healthcare Provider Details

I. General information

NPI: 1740273754
Provider Name (Legal Business Name): JONATHAN EDWARD MICETICH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E NORTH STREET
COAL CITY IL
60416-1087
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 815-634-4825
  • Fax: 815-634-4938
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008925
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: