Provider Demographics
NPI:1528153509
Name:HERBERTS, JEFFREY P (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:P
Last Name:HERBERTS
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 1:119 N MORRISON AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-3226
Mailing Address - Country:US
Mailing Address - Phone:618-344-0511
Mailing Address - Fax:618-344-0545
Practice Address - Street 1:119 N MORRISON AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-3226
Practice Address - Country:US
Practice Address - Phone:618-344-0511
Practice Address - Fax:618-344-0545
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37222Medicare UPIN
IL0460220001Medicare NSC