Provider Demographics
NPI:1710190756
Name:DRS. DISTIN & DOYLE, OPTOMETRISTS
Entity Type:Organization
Organization Name:DRS. DISTIN & DOYLE, OPTOMETRISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DISTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-582-5673
Mailing Address - Street 1:2108 S. E. THIRD ST
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-9456
Mailing Address - Country:US
Mailing Address - Phone:309-582-5673
Mailing Address - Fax:309-582-5674
Practice Address - Street 1:2108 S. E 3D ST
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-9456
Practice Address - Country:US
Practice Address - Phone:309-582-5673
Practice Address - Fax:309-582-5674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL769081Medicare ID - Type UnspecifiedMEDICARE
IL0284560002Medicare NSC