Provider Demographics
NPI:1629155379
Name:SPOONER, BRIAN S (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:SPOONER
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 1:3400 BROADWAY
Mailing Address - Street 2:QUINCY MALL
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3716
Mailing Address - Country:US
Mailing Address - Phone:217-228-9571
Mailing Address - Fax:217-228-9571
Practice Address - Street 1:3400 QUINCY MALL
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4640
Practice Address - Country:US
Practice Address - Phone:217-228-4204
Practice Address - Fax:217-228-4218
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU57300Medicare UPIN