Healthcare Provider Details

I. General information

NPI: 1104812650
Provider Name (Legal Business Name): JON E MCCUTCHAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ACE RD SUITE 4
PRINCETON IL
61356-8644
US

IV. Provider business mailing address

200 ACE RD SUITE 4
PRINCETON IL
61356-8644
US

V. Phone/Fax

Practice location:
  • Phone: 815-872-3937
  • Fax: 815-875-3937
Mailing address:
  • Phone: 815-872-3937
  • Fax: 815-875-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0046008749
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: