Provider Demographics
NPI:1336131259
Name:BACKUS, ANDREW W (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:W
Last Name:BACKUS
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 1:6 HEARTLAND DR STE C
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7737
Mailing Address - Country:US
Mailing Address - Phone:309-663-0303
Mailing Address - Fax:309-663-0161
Practice Address - Street 1:6 HEARTLAND DR
Practice Address - Street 2:SUITE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7736
Practice Address - Country:US
Practice Address - Phone:309-663-0303
Practice Address - Fax:309-663-0161
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2014-08-11
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
IL046-006702152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4630920001Medicare NSC
ILT37788Medicare UPIN
IL680750Medicare PIN