Provider Demographics
NPI:1093832008
Name:J. MICETICH, OD & ASSOCIATES FAMILY EYE CARE CENTER P C
Entity Type:Organization
Organization Name:J. MICETICH, OD & ASSOCIATES FAMILY EYE CARE CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MICETICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-634-4825
Mailing Address - Street 1:2920 GATEWAY GORGE
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-9771
Mailing Address - Country:US
Mailing Address - Phone:815-634-4825
Mailing Address - Fax:
Practice Address - Street 1:20 E NORTH ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1087
Practice Address - Country:US
Practice Address - Phone:815-634-4825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008925152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008925Medicaid
IL03232003OtherBCBS
IL1740273754OtherPERSONAL NPI
DR0848OtherRAILROAD MEDICARE GROUP PTAN
410047901OtherRAILROAD MEDICARE GROUP MEMBER PTAN
DR0848OtherRAILROAD MEDICARE GROUP PTAN
IL03232003OtherBCBS