=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730898263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AEG RHODE ISLAND PROFESSIONAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2022
-----------------------------------------------------
Last Update Date | 04/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 DEXTER ST
-----------------------------------------------------
City | PAWTUCKET
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02860-2996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-723-9540
-----------------------------------------------------
Fax | 314-741-4947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 E 4TH ST STE 440
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-6206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-462-9818
-----------------------------------------------------
Fax | 314-741-4947
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JONATHAN KAPLAN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 618-462-9818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------