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General NPI Number Information
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NPI Number | 1356525489
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Entity Type | Organization
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Legal Business Name | JEFFREY S PORTER OD PC
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Dates
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Enumeration Date | 12/26/2007
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Last Update Date | 08/20/2020
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Provider Practice Location Address
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Address Line | 1205 S IL ROUTE 31
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-8213
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Country | US
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Telephone | 915-477-4053
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Fax | 815-477-4302
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Provider Business Mailing Address
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Address Line | 3912 VALLEY VIEW RD
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City | CRYSTAL LAKE
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State | IL
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Zip | 60012-2104
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Country | US
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Telephone | 815-479-9246
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JEFFREY SCOTT PORTER
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Credential | O.D.
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Telephone | 847-323-8501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 04608991
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License Number State | IL
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