MEDICARE: DR. JASPER J GULOTTA 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
1	152W00000X	Optometrist	046-7183	IL

General Provider Information

NPI Number	:	1669464251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASPER J GULOTTA O.D.

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	11/15/2007

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