Provider Demographics
NPI:1740273754
Name:MICETICH, JONATHAN EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EDWARD
Last Name:MICETICH
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:20 E NORTH STREET
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1087
Practice Address - Country:US
Practice Address - Phone:815-634-4825
Practice Address - Fax:815-634-4938
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008925152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008925Medicaid
IL3232003OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
IL5075840001OtherNATIONAL GOVERMENT SERVICES
ILU63669Medicare UPIN
IL202933Medicare ID - Type UnspecifiedPART B