Provider Demographics
NPI:1972510345
Name:MASSIE, DIRK F (OD)
Entity Type:Individual
Prefix:DR
First Name:DIRK
Middle Name:F
Last Name:MASSIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7609
Mailing Address - Country:US
Mailing Address - Phone:618-234-3053
Mailing Address - Fax:168-234-6331
Practice Address - Street 1:4111 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-7609
Practice Address - Country:US
Practice Address - Phone:618-234-3053
Practice Address - Fax:168-234-6331
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-9417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU87226Medicare UPIN
IL212342Medicare ID - Type UnspecifiedMEDICARE NUMBER