Provider Demographics
NPI:1598594855
Name:PROSSER, MAXWELL (OD)
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:PROSSER
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 1:704 S SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-4677
Mailing Address - Country:US
Mailing Address - Phone:217-474-1670
Mailing Address - Fax:
Practice Address - Street 1:1104 N VERMILION ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3094
Practice Address - Country:US
Practice Address - Phone:217-398-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist