Provider Demographics
NPI:1598757304
Name:GYSIN, JOHN PHILLIP (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILLIP
Last Name:GYSIN
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 1:5901 N PROSPECT RD STE 11
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4337
Mailing Address - Country:US
Mailing Address - Phone:309-692-2525
Mailing Address - Fax:309-692-2584
Practice Address - Street 1:5901 N PROSPECT RD
Practice Address - Street 2:SUITE #11
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4358
Practice Address - Country:US
Practice Address - Phone:309-692-2525
Practice Address - Fax:309-692-2584
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0046007961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007961Medicaid
IL046007961Medicaid
ILT92355Medicare UPIN
ILP00447730Medicare PIN
IL0736460001Medicare NSC