Healthcare Provider Details

I. General information

NPI: 1619056629
Provider Name (Legal Business Name): JONATHAN LEONARD OTTINO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 PRAIRIE CROSSING DRIVE
SPRINGFIELD IL
62711
US

IV. Provider business mailing address

2741 PRAIRIE CROSSING DRIVE
SPRINGFIELD IL
62711
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-3233
  • Fax: 217-726-4054
Mailing address:
  • Phone: 217-528-3233
  • Fax: 217-726-4054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-009536
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: