Provider Demographics
NPI:1417514134
Name:GERSON, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:IL
Mailing Address - Zip Code:62012-1053
Mailing Address - Country:US
Mailing Address - Phone:618-372-7000
Mailing Address - Fax:618-372-7003
Practice Address - Street 1:101 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:IL
Practice Address - Zip Code:62012-1053
Practice Address - Country:US
Practice Address - Phone:618-372-7000
Practice Address - Fax:618-372-7003
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011301152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist