MEDICARE: KAITLIN GRIFFITH 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	046010765	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01733864	OTHER	IL	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1760894935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLIN GRIFFITH O.D.

Provider Business Mailing Address
First Line	:	8309 N KNOXVILLE AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615-2170
Country	:	US
Telephone Number	:	309-693-9540
Fax Number	:	309-693-9754

Provider Business Practice Location Address
First Line	:	1689 W MORTON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-2717
Country	:	US
Telephone Number	:	217-245-8800
Fax Number	:

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

Provider Enumeration Date	:	05/22/2014
Last Update Date	:	09/17/2019

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