Provider Demographics
NPI:1154375392
Name:BOUTON, BRIAN (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:BOUTON
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 1:2537 PLAINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1463
Mailing Address - Country:US
Mailing Address - Phone:815-577-2020
Mailing Address - Fax:815-577-0998
Practice Address - Street 1:2537 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1463
Practice Address - Country:US
Practice Address - Phone:815-577-2020
Practice Address - Fax:815-577-0998
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009919581OtherBLUE CROSS BLUE SHIELD IL
IL046009118Medicaid
IL1457618621OtherAETNA
ILU72940Medicare UPIN
ILIL7483Medicare Oscar/Certification