Provider Demographics
NPI:1437375029
Name:DRS. DISTIN & DOYLE, OPTOMETRISTS
Entity Type:Organization
Organization Name:DRS. DISTIN & DOYLE, OPTOMETRISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DISTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-734-3108
Mailing Address - Street 1:67 PUBLIC SQ
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-1755
Mailing Address - Country:US
Mailing Address - Phone:309-734-3108
Mailing Address - Fax:309-734-6988
Practice Address - Street 1:67 PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1755
Practice Address - Country:US
Practice Address - Phone:309-734-3108
Practice Address - Fax:309-734-6988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILEACH DR HAS LICENSE152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009484001OtherBLUE CROSS BLUE SHIELD
IL0284560001Medicare NSC
IL769080Medicare ID - Type Unspecified