Provider Demographics
NPI:1679128177
Name:PODPESKAR, NICHOLAS JOSEPH (OD)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:PODPESKAR
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 1:216 NW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GALVA
Mailing Address - State:IL
Mailing Address - Zip Code:61434-1302
Mailing Address - Country:US
Mailing Address - Phone:309-932-3615
Mailing Address - Fax:309-932-2023
Practice Address - Street 1:216 NW 1ST ST
Practice Address - Street 2:
Practice Address - City:GALVA
Practice Address - State:IL
Practice Address - Zip Code:61434-1302
Practice Address - Country:US
Practice Address - Phone:309-932-3615
Practice Address - Fax:309-932-2023
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist