Provider Demographics
NPI:1669464251
Name:GULOTTA, JASPER J (OD)
Entity Type:Individual
Prefix:DR
First Name:JASPER
Middle Name:J
Last Name:GULOTTA
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 1:835 E 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2465
Mailing Address - Country:US
Mailing Address - Phone:708-333-4444
Mailing Address - Fax:708-333-4454
Practice Address - Street 1:835 E 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2465
Practice Address - Country:US
Practice Address - Phone:708-333-4444
Practice Address - Fax:708-333-4454
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-7183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
685470Medicare PIN
IL0321200001Medicare NSC
ILT37830Medicare UPIN