Provider Demographics
NPI:1104899053
Name:BROTHERS, JOHN EVERD (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EVERD
Last Name:BROTHERS
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 1:1901 KENSINGTON KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-8537
Mailing Address - Country:US
Mailing Address - Phone:217-359-4111
Mailing Address - Fax:217-459-9870
Practice Address - Street 1:1104 N VERMILION ST
Practice Address - Street 2:CHITTICK FAMILY EYE CARE
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3094
Practice Address - Country:US
Practice Address - Phone:217-442-2631
Practice Address - Fax:217-442-0119
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007703152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL16361OtherCOLE MANAGED VISION
IL216981OtherPERSONAL CARE
ILU33555Medicare UPIN