1780875898 NPI number — JANNA F BROCKMAN O.D.

Table of content: JANNA F BROCKMAN O.D. (NPI 1780875898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780875898 NPI number — JANNA F BROCKMAN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCKMAN
Provider First Name:
JANNA
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LINDEMULDER
Provider Other First Name:
JANNA
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
JANNA JASPER OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780875898
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5985 LAKESIDE PL
Provider Second Line Business Mailing Address:
UNIT 304
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60477-1985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-614-0558
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 LINCOLN MALL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTESON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60443-2328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-481-8722
Provider Business Practice Location Address Fax Number:
708-481-8719
Provider Enumeration Date:
08/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046009967 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)