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NPI Code Detail

MEDICARE: DR. ROBERT SHEDD JUCKETT JR. O.D.

MEDICARE: DR. ROBERT SHEDD JUCKETT JR. O.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometristIL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1168454OTHERILBLUE CROSS BLUE SHIELD IL

General Provider Information

NPI Number : 1285792168
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ROBERT SHEDD JUCKETT JR. O.D.
Provider Business Mailing Address
First Line : 133 S NORTHWEST HWY
Second Line :
City : PARK RIDGE
State : IL
Zip : 60068-4228
Country : US
Telephone Number : 847-384-2020
Fax Number : 847-823-2020
Provider Business Practice Location Address
First Line : 133 S NORTHWEST HWY
Second Line :
City : PARK RIDGE
State : IL
Zip : 60068-4228
Country : US
Telephone Number : 847-384-2020
Fax Number : 847-823-2020
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/04/2006
Last Update Date : 07/08/2007

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