Individual
DR. JONATHAN EDWARD MICETICH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
20 E NORTH STREET, COAL CITY, IL 60416-1087
(815) 634-4825
(815) 634-4938
Mailing address
1950 OLD GALLOWS RD STE 520, VIENNA, VA 22182-3970
(703) 847-8899
(571) 223-6780
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046008925
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
046008925
—
IL
01
—
3232003
BLUE CROSS BLUE SHIELD OF ILLINOIS
IL
01
—
5075840001
NATIONAL GOVERMENT SERVICES
IL
Enumeration date
08/24/2005
Last updated
03/25/2021
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