Provider Demographics
NPI:1457301368
Name:BOTTS, ERIC (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:BOTTS
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 1:1730 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2531
Mailing Address - Country:US
Mailing Address - Phone:309-836-3373
Mailing Address - Fax:309-836-3373
Practice Address - Street 1:1730 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2531
Practice Address - Country:US
Practice Address - Phone:309-836-3373
Practice Address - Fax:309-836-3373
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008560152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008560Medicaid
ILU35574Medicare UPIN
IL046008560Medicaid