Provider Demographics
NPI:1821248287
Name:MICHAEL S. FELDT, O.D., LTD.
Entity Type:Organization
Organization Name:MICHAEL S. FELDT, O.D., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FELDT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-397-1487
Mailing Address - Street 1:1640 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-6000
Mailing Address - Country:US
Mailing Address - Phone:815-397-1487
Mailing Address - Fax:815-397-3435
Practice Address - Street 1:1640 BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-6000
Practice Address - Country:US
Practice Address - Phone:815-397-1487
Practice Address - Fax:815-397-3435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT35297Medicare UPIN
IL205940Medicare PIN
IL0489830001Medicare NSC