Provider Demographics
NPI:1134432149
Name:MASEK, ELIOT G (OD)
Entity type:Individual
Prefix:DR
First Name:ELIOT
Middle Name:G
Last Name:MASEK
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 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:537 W KARSCH BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3312
Practice Address - Country:US
Practice Address - Phone:573-747-4133
Practice Address - Fax:573-747-4533
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010396152W00000X, 152WL0500X
MO2011037694152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010396Medicaid
IL502720031Medicare PIN