Organization
J. MICETICH, OD & ASSOCIATES FAMILY EYE CARE CENTER P C
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JONATHAN EDWARD MICETICH O.D. (OPTOMETRIST)
(815) 634-4825
Entity
Organization
Contact information
Practice address
20 E NORTH ST, COAL CITY, IL 60416-1087
(815) 634-4825
Mailing address
2920 GATEWAY GORGE, MORRIS, IL 60450-9771
(815) 634-4825
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046-008925
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03232003
BCBS
IL
05
—
046008925
—
IL
01
—
1740273754
PERSONAL NPI
IL
01
—
410047901
RAILROAD MEDICARE GROUP MEMBER PTAN
—
01
—
DR0848
RAILROAD MEDICARE GROUP PTAN
—
Enumeration date
03/23/2007
Last updated
09/18/2012
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