Active NPI
Jay Charles Black, OD
- Optometrist
- Loves Park, IL
National Provider Identifier
1629113261
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 466709
- Practice address
- 5316 N Second Street
Loves Park, IL 61111-5009 - Phone
- (815) 877-6551
- Fax
- (815) 877-4821
- NPI assigned
- Feb 21, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 466709 | IL | Primary |
Addresses
Primary practice location
5316 N Second Street
Loves Park, IL 61111-5009
Mailing address
5316 N Second Street
Loves Park, IL 61111-5009
Phone (815) 877-6551
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 362871342 | Other | IL | FED ID NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 466709 | IL | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172016000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1629113261",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5316 N SECOND STREET",
"city": "LOVES PARK",
"state": "IL",
"postal_code": "611115009",
"telephone_number": "815-877-6551",
"fax_number": "815-877-4821"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5316 N SECOND STREET",
"city": "LOVES PARK",
"state": "IL",
"postal_code": "611115009",
"telephone_number": "815-877-6551",
"fax_number": "815-877-4821"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BLACK",
"first_name": "JAY",
"middle_name": "CHARLES",
"name_prefix": "Dr.",
"credential": "OD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-02-21",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "IL",
"license": "466709",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FED ID NUMBER",
"identifier": "362871342",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Loves Park, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.