Provider Demographics
NPI:1225183999
Name:BARTLETT, JOHN JACOB SR (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACOB
Last Name:BARTLETT
Suffix:SR
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 1:5111 N BOGUS BASIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-1548
Mailing Address - Country:US
Mailing Address - Phone:630-337-2374
Mailing Address - Fax:
Practice Address - Street 1:510 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5104
Practice Address - Country:US
Practice Address - Phone:630-858-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100332152W00000X
IL46-7734152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT88659Medicare UPIN
ILL28051Medicare PIN