Provider Demographics
NPI:1992755516
Name:PESAVENTO, D DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:D
Middle Name:DAVID
Last Name:PESAVENTO
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 1:963 N 129TH INFANTRY DR
Mailing Address - Street 2:SUITE110
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3104
Mailing Address - Country:US
Mailing Address - Phone:815-725-8425
Mailing Address - Fax:815-725-2607
Practice Address - Street 1:963 129TH INFANTRY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-725-8425
Practice Address - Fax:815-725-2607
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP1396387OtherPEA
IL0797670001Medicare NSC
T37961Medicare UPIN
IL697700Medicare ID - Type Unspecified