Healthcare Provider Details

I. General information

NPI: 1760450696
Provider Name (Legal Business Name): JOHN J. KONOPIK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 WINDING WOODS CTR
O FALLON MO
63366-4170
US

IV. Provider business mailing address

211 E BROADWAY
ALTON IL
62002-6220
US

V. Phone/Fax

Practice location:
  • Phone: 636-281-5367
  • Fax: 800-432-6004
Mailing address:
  • Phone: 618-462-9818
  • Fax: 800-432-6004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2005019551
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: