Provider Demographics
NPI:1922242379
Name:JOHN P GYSIN OD
Entity Type:Organization
Organization Name:JOHN P GYSIN OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GYSIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-692-2525
Mailing Address - Street 1:5901 N PROSPECT RD STE 11
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4337
Mailing Address - Country:US
Mailing Address - Phone:309-692-2525
Mailing Address - Fax:309-692-2584
Practice Address - Street 1:5901 N PROSPECT RD STE 11
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4337
Practice Address - Country:US
Practice Address - Phone:309-692-2525
Practice Address - Fax:309-692-2584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0046007961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty