=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982602918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN ROBERT EIGENBRODT O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2005
-----------------------------------------------------
Last Update Date | 06/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 EDWARDSVILLE CLUB PLAZA
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-3517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-656-3199
-----------------------------------------------------
Fax | 618-656-3099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 EDWARDSVILLE CLUB PLAZA
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-3517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-656-3199
-----------------------------------------------------
Fax | 618-656-3099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046008144
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------