Provider Demographics
NPI:1326246489
Name:VAN HOUTEN, WINONA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:WINONA
Middle Name:MARIE
Last Name:VAN HOUTEN
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 1:4891 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PLAINS
Mailing Address - State:IL
Mailing Address - Zip Code:62677-3997
Mailing Address - Country:US
Mailing Address - Phone:217-361-6286
Mailing Address - Fax:
Practice Address - Street 1:1705 W MORTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2719
Practice Address - Country:US
Practice Address - Phone:217-245-6070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.009980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9980OtherEYEMED
MO310350509Medicaid
138476OtherHEALTH ALLIANCE
P00418696, CA2196OtherMEDICARE RAILROAD
IL046009980Medicaid
ILK39382Medicare PIN