Provider Demographics
NPI:1679644496
Name:HUETTEMANN, JEFFREY A (OPTOMETRIST)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:HUETTEMANN
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 VISA DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2137
Mailing Address - Country:US
Mailing Address - Phone:309-454-2472
Mailing Address - Fax:309-454-3029
Practice Address - Street 1:1607 VISA DR
Practice Address - Street 2:SUITE 4
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2137
Practice Address - Country:US
Practice Address - Phone:309-454-2472
Practice Address - Fax:309-454-3029
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-008558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008558Medicaid
ILU80116Medicare UPIN