=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376953042
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN RYAN ISGRIG OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2014
-----------------------------------------------------
Last Update Date | 12/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 TANGLEFOOT LN
-----------------------------------------------------
City | BETTENDORF
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52722-1650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-459-6676
-----------------------------------------------------
Fax | 563-459-6615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 5TH ST SUITE 49
-----------------------------------------------------
City | SILVIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61282-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-459-6676
-----------------------------------------------------
Fax | 563-459-6615
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046.010894
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------