=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073756490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VINTAGE OPTICAL BRIAN C SOMMER OD LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2009
-----------------------------------------------------
Last Update Date | 12/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 S MAIN ST
-----------------------------------------------------
City | MORTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61550-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-263-8611
-----------------------------------------------------
Fax | 309-263-8926
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 S MAIN ST
-----------------------------------------------------
City | MORTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61550-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-263-8611
-----------------------------------------------------
Fax | 309-263-8926
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAUL O VELTING
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 309-263-8611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046.007309
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------