Provider Demographics
NPI:1568717023
Name:PLUMMER, NELLIE N (OD)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:N
Last Name:PLUMMER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20303 CRAWFORD AVE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1073
Mailing Address - Country:US
Mailing Address - Phone:708-898-1858
Mailing Address - Fax:708-898-1860
Practice Address - Street 1:20303 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1073
Practice Address - Country:US
Practice Address - Phone:708-898-1858
Practice Address - Fax:708-898-1860
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1636706OtherBCBS
IL8825444OtherMULTIPLAN
IL7235044OtherAETNA
IL7235044OtherAETNA
IL210209Medicare PIN
IL0757500001Medicare NSC