Provider Demographics
NPI:1508940123
Name:PETECKI, ERIC JON (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JON
Last Name:PETECKI
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 1:1230 N CEDAR RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1272
Mailing Address - Country:US
Mailing Address - Phone:815-485-6533
Mailing Address - Fax:815-485-6534
Practice Address - Street 1:1230 N CEDAR RD UNIT A
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1272
Practice Address - Country:US
Practice Address - Phone:815-485-6533
Practice Address - Fax:815-485-6534
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009282OtherSTATE LICENSE NUMBER
ILU81691Medicare UPIN