Gary D Distin, OD
Individual provider Active NPI Optometrist · Monmouth, IL
NPI 1477548287 · NPPES record last updated May 25, 2010
Key facts
- NPI
- 1477548287
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- 046006527 (IL)
- Practice address
- 67 Public SQ
Monmouth, IL 61462-1755 - Phone
- (309) 734-3108
- Fax
- (309) 734-6988
- NPI assigned
- Sep 19, 2005
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 046006527 | IL | Yes |
Addresses
Primary practice location
67 Public SQ
Monmouth, IL 61462-1755
Mailing address
67 Public SQ
Monmouth, IL 61462-1755
Phone (309) 734-3108
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 046006527 | Medicaid | IL |
Other providers in Monmouth, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 25, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.