Healthcare Provider Details

I. General information

NPI: 1730189754
Provider Name (Legal Business Name): JOHN EMMERT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 LA SALLE ST
OTTAWA IL
61350-2018
US

IV. Provider business mailing address

2918 E 1979TH RD
MARSEILLES IL
61341-9308
US

V. Phone/Fax

Practice location:
  • Phone: 815-433-4100
  • Fax:
Mailing address:
  • Phone: 815-434-2883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: