Provider Demographics
NPI:1124225180
Name:SKIBO, EMILY ELLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:ELLEN
Last Name:SKIBO
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 1:4200 ILBERRY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6748
Mailing Address - Country:US
Mailing Address - Phone:618-242-6338
Mailing Address - Fax:618-242-0465
Practice Address - Street 1:4200 ILBERRY RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6748
Practice Address - Country:US
Practice Address - Phone:618-242-6338
Practice Address - Fax:618-242-0465
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.009973152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00650602 CA2196OtherMEDICARE RAILROAD
IL046009973Medicaid
ILR03442Medicare UPIN