Basic Information
| Provider Information | |||||||||
| NPI: | 1578568077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUMTHAL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 W ILES AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627047015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176984728 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 W ILES AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627044174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176983068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 02/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046007512 | IL | Y | Eye and Vision Services Providers | Optometrist | 152WC0802X | 046007512 | IL | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WL0500X | 046007512 | IL | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 046007512 | 05 | IL | MEDICAID | 410033847 | 01 | IL | RAILROAD MEDICARE | OTHER |