Provider Demographics
NPI:1649629072
Name:POPOVICH, PETER JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:POPOVICH
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 1:511 PALMYRA ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1953
Mailing Address - Country:US
Mailing Address - Phone:815-284-2020
Mailing Address - Fax:815-284-8326
Practice Address - Street 1:511 PALMYRA ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1953
Practice Address - Country:US
Practice Address - Phone:815-284-2020
Practice Address - Fax:815-284-8326
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010978152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400568269OtherMEDICARE PTAN
IL046010978Medicaid