MEDICARE: JASPER GULOTTA

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
1	332H00000X	Eyewear Supplier
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1497937403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JASPER GULOTTA

Provider Business Mailing Address
First Line	:	835 E 162ND ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2465
Country	:	US
Telephone Number	:	708-333-4444
Fax Number	:	708-333-4454

Provider Business Practice Location Address
First Line	:	835 E 162ND ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2465
Country	:	US
Telephone Number	:	708-333-4444
Fax Number	:	708-333-4454

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JASPER JAY GULOTTA
Credential	:	O.D.
Telephone Number	:	708-333-4444

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	08/28/2009

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Directions to “JASPER GULOTTA ” Practice Location

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