Provider Demographics
NPI:1902880057
Name:PIETRZYK, JEFFREY MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:PIETRZYK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 W NORTH ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-8201
Mailing Address - Country:US
Mailing Address - Phone:815-478-0100
Mailing Address - Fax:815-478-9100
Practice Address - Street 1:540 W NORTH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-8201
Practice Address - Country:US
Practice Address - Phone:815-478-0100
Practice Address - Fax:815-478-9100
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1553DT152W00000X
IL046-009714152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0009932433OtherBCBS PIN
IL046009714Medicaid
P00313497OtherMEDICARE RAILROAD PIN
U91100Medicare UPIN
K25852Medicare PIN