Provider Demographics
NPI:1114062288
Name:ALBERT, JODI M (JODI M ALBERT)
Entity Type:Individual
Prefix:
First Name:JODI M
Middle Name:
Last Name:ALBERT
Suffix:
Gender:F
Credentials:JODI M ALBERT
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:MAUREEN
Other - Last Name:ALBERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JODI M ALBERT
Mailing Address - Street 1:505 S NEIL ST
Mailing Address - Street 2:SUITE NUMBER 4
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5231
Mailing Address - Country:US
Mailing Address - Phone:217-356-5787
Mailing Address - Fax:217-356-0655
Practice Address - Street 1:505 S NEIL ST
Practice Address - Street 2:4
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-5231
Practice Address - Country:US
Practice Address - Phone:217-356-5787
Practice Address - Fax:217-356-0655
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008689152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK49540Medicare PIN