Healthcare Provider Details

I. General information

NPI: 1578568077
Provider Name (Legal Business Name): ROBERT JAMES BLUMTHAL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

IV. Provider business mailing address

2020 W ILES AVE
SPRINGFIELD IL
62704-7015
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-3030
  • Fax: 217-698-3068
Mailing address:
  • Phone: 217-698-3030
  • Fax: 217-698-4728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007512
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046007512
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number046007512
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: