Provider Demographics
NPI:1467685180
Name:JONATHAN L OTTINO, O.D., P.C.
Entity Type:Organization
Organization Name:JONATHAN L OTTINO, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:OTTINO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:224-558-6357
Mailing Address - Street 1:3617 N GRAND AVE E TRLR 259
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-8505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 LEJUNE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4537
Practice Address - Country:US
Practice Address - Phone:224-558-6357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009536152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty