Provider Demographics
NPI:1356775720
Name:KVITLE, JASON MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MICHAEL
Last Name:KVITLE
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 1:3325 MAINE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4438
Mailing Address - Country:US
Mailing Address - Phone:217-231-3937
Mailing Address - Fax:217-231-3940
Practice Address - Street 1:3325 MAINE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4438
Practice Address - Country:US
Practice Address - Phone:217-231-3937
Practice Address - Fax:217-231-3940
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010731152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist