Provider Demographics
NPI:1114282548
Name:THOELE, JONATHON PAUL (OD)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:PAUL
Last Name:THOELE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3257
Mailing Address - Country:US
Mailing Address - Phone:217-222-9207
Mailing Address - Fax:217-222-9205
Practice Address - Street 1:105 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT STERLING
Practice Address - State:IL
Practice Address - Zip Code:62353-1223
Practice Address - Country:US
Practice Address - Phone:217-773-3055
Practice Address - Fax:217-773-3522
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012025597152W00000X
IA002553152W00000X
IL046010606152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1114282548Medicaid
MO1114282548Medicaid
IL1114282548Medicaid