Healthcare Provider Details

I. General information

NPI: 1942684642
Provider Name (Legal Business Name): BRIAN REPKING O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E MAIN ST
TEUTOPOLIS IL
62467-1340
US

IV. Provider business mailing address

113 E MAIN ST
TEUTOPOLIS IL
62467-1340
US

V. Phone/Fax

Practice location:
  • Phone: 217-903-4117
  • Fax: 217-903-4116
Mailing address:
  • Phone: 217-903-4117
  • Fax: 217-903-4116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.010915
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: