Healthcare Provider Details

I. General information

NPI: 1003986522
Provider Name (Legal Business Name): BRIAN C SOMMER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 W JEFFERSON ST
MORTON IL
61550-1817
US

IV. Provider business mailing address

417 W JEFFERSON ST
MORTON IL
61550-1817
US

V. Phone/Fax

Practice location:
  • Phone: 309-263-8611
  • Fax: 309-263-8926
Mailing address:
  • Phone: 309-263-8611
  • Fax: 309-263-8926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-007309
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: