Healthcare Provider Details

I. General information

NPI: 1497937403
Provider Name (Legal Business Name): JASPER GULOTTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 E 162ND ST
SOUTH HOLLAND IL
60473-2465
US

IV. Provider business mailing address

835 E 162ND ST
SOUTH HOLLAND IL
60473-2465
US

V. Phone/Fax

Practice location:
  • Phone: 708-333-4444
  • Fax: 708-333-4454
Mailing address:
  • Phone: 708-333-4444
  • Fax: 708-333-4454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. JASPER JAY GULOTTA
Title or Position: OWNER
Credential: O.D.
Phone: 708-333-4444