Provider Demographics
NPI:1073613279
Name:HERMAN, JANE (OD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:HERMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 W DEYOUNG ST STE 500
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5551
Mailing Address - Country:US
Mailing Address - Phone:618-993-4484
Mailing Address - Fax:618-997-3003
Practice Address - Street 1:3000 W DEYOUNG ST STE 500
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5551
Practice Address - Country:US
Practice Address - Phone:618-993-4484
Practice Address - Fax:618-997-3003
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT39184Medicare UPIN
IL793242Medicare ID - Type Unspecified