Provider Demographics
NPI:1730189754
Name:EMMERT, JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:EMMERT
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 1:2918 E 1979TH RD
Mailing Address - Street 2:
Mailing Address - City:MARSEILLES
Mailing Address - State:IL
Mailing Address - Zip Code:61341-9308
Mailing Address - Country:US
Mailing Address - Phone:815-434-2883
Mailing Address - Fax:
Practice Address - Street 1:1029 LA SALLE ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-2018
Practice Address - Country:US
Practice Address - Phone:815-433-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37726Medicare UPIN
IL674990Medicare PIN