Healthcare Provider Details

I. General information

NPI: 1982602918
Provider Name (Legal Business Name): JOHN ROBERT EIGENBRODT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 EDWARDSVILLE CLUB PLAZA
EDWARDSVILLE IL
62025-3517
US

IV. Provider business mailing address

1950 EDWARDSVILLE CLUB PLAZA
EDWARDSVILLE IL
62025-3517
US

V. Phone/Fax

Practice location:
  • Phone: 618-656-3199
  • Fax: 618-656-3099
Mailing address:
  • Phone: 618-656-3199
  • Fax: 618-656-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008144
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: