Provider Demographics
NPI:1821052846
Name:HETTIGER, LEO FRANK (OPTOMETRIST)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:FRANK
Last Name:HETTIGER
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 1:1205 N OLIVE RD
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-2344
Mailing Address - Country:US
Mailing Address - Phone:618-662-4045
Mailing Address - Fax:618-662-3402
Practice Address - Street 1:1205 N OLIVE RD
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-2344
Practice Address - Country:US
Practice Address - Phone:618-662-4045
Practice Address - Fax:618-662-3402
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007547152WS0006X
MOT02518152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0562850001Medicare NSC
IL697390Medicare ID - Type Unspecified
T37960Medicare UPIN