Healthcare Provider Details

I. General information

NPI: 1093128886
Provider Name (Legal Business Name): PAUL O VELTING O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 08/17/2016
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:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046.010793
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: