Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 152WP0200X | Optometrist | Pediatrics | 046010543 | ILLINOIS | No |
| 2 | 152W00000X | Optometrist | | 046010543 | ILLINOIS | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 200871680A | OTHER | INDIANA | MUNSTER LOCATION ID LEGACY PTAN # 200871680A |
| 2 | 12385422 | OTHER | ILLINOIS | CAQH |
| 3 | 253350 | OTHER | ILLINOIS | ILLINOIS MEDICARE GROUP PTAN 253350 |
| 4 | 046010543 | MEDICAID | ILLINOIS | |
| 5 | 14D2054175 | OTHER | ILLINOIS | CLIA # 14D2054175 EXP 2-14-2015 CHICAGO RIDGE LOCATION |
| 6 | 200871680C | OTHER | INDIANA | ORLAND PARK LOCATION ID INDIANA MEDICAID LEGACY PTAN # 200871680C |
| 7 | 200871680D | OTHER | INDIANA | HINSDALE LOCATION ID INDIANA MEDICAID LEGACY PTAN # 200871680D |
| 8 | 1083684922 | OTHER | INDIANA | THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922 |
| 9 | 1699802421 | OTHER | ILLINOIS | OPTICAL THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1699802421 |
| 10 | 502720062 | OTHER | ILLINOIS | MEDICARE PTAN |
| 11 | 1083684922 | OTHER | ILLINOIS | THE EYE SPECIALISTS CENTER, LLC GROUP NPI 1083684922 |
| 12 | 1700191012 | OTHER | ILLINOIS | UNIVERSITY OF CHICAGO MEDICAL CENTER NPI |
| 13 | 253350 | OTHER | INDIANA | INDIANA MEDICARE GROUP PTAN 253350 |
| 14 | 6180260001 | OTHER | ILLINOIS | DEMERC SUPPLIER PTAN 6180260001 THE EYE SPECIALISTS CENTER, LLC |
| 15 | CK7818 | OTHER | ILLINOIS | RAILROAD MEDICARE ESC GROUP# CK7818 |
| 16 | 01621679 | OTHER | ILLINOIS | BLUE CROSS & BLUE SHEILD ESC # 01621679 |
| 17 | 200871680 | OTHER | INDIANA | INDIANA GROUP MEDICAID LEGACY PTAN # 200871680 |
| 18 | 200871680B | OTHER | INDIANA | CHICAGO RIDGE LOCATION ID INDIANA MEDICAID LEGACY PTAN # 200871680B |
