MEDICARE: DR. JONATHAN EDWARD MICETICH 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	046008925	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3232003	OTHER	IL	BLUE CROSS BLUE SHIELD OF ILLINOIS
3	5075840001	OTHER	IL	NATIONAL GOVERMENT SERVICES

General Provider Information

NPI Number	:	1740273754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN EDWARD MICETICH O.D.

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	20 E NORTH STREET
Second Line	:
City	:	COAL CITY
State	:	IL
Zip	:	60416-1087
Country	:	US
Telephone Number	:	815-634-4825
Fax Number	:	815-634-4938

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	03/25/2021

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