Healthcare Provider Details

I. General information

NPI: 1760652044
Provider Name (Legal Business Name): WILLIAM H BEDWELL OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W MEFFORD
ROBINSON IL
62454-1065
US

IV. Provider business mailing address

905 W MEFFORD
ROBINSON IL
62454-1065
US

V. Phone/Fax

Practice location:
  • Phone: 618-544-3525
  • Fax: 618-544-3261
Mailing address:
  • Phone: 618-544-3525
  • Fax: 618-544-3261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007815
License Number StateIL

VIII. Authorized Official

Name: WILLIAM BEDWELL
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 618-544-3525