Healthcare Provider Details

I. General information

NPI: 1285953844
Provider Name (Legal Business Name): JILL MOGIL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL MIROWITZ O.D.

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 N BALLAS RD STE C11
SAINT LOUIS MO
63131-2313
US

IV. Provider business mailing address

PO BOX 11805
CLAYTON MO
63105-0605
US

V. Phone/Fax

Practice location:
  • Phone: 833-376-6445
  • Fax: 314-312-6984
Mailing address:
  • Phone: 888-376-6445
  • Fax: 314-312-6984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007879
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2571
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberT02571
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: