1942321252 NPI number — DR. JANICE PETERSEN EASTY O.D.

Table of content: DR. JANICE PETERSEN EASTY O.D. (NPI 1942321252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942321252 NPI number — DR. JANICE PETERSEN EASTY O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EASTY
Provider First Name:
JANICE
Provider Middle Name:
PETERSEN
Provider Name Prefix Text:
DR.
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942321252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
470 OXFORD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRYSTAL LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60014-5525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-459-7519
Provider Business Mailing Address Fax Number:
815-356-8141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7200 HARRISON AVE
Provider Second Line Business Practice Location Address:
F35
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61112-1017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-332-8228
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2007

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 , 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)





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