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 | 156FX1202X | Technician/Technologist | Optometric Technician | 036082457 | ILLINOIS | No |
| 2 | 207W00000X | Ophthalmology | | 036082457 | ILLINOIS | Yes |
| 3 | 207W00000X | Ophthalmology | | 01070796A | INDIANA | No |
| 4 | 207WX0110X | Ophthalmology | Pediatric Ophthalmology and Strabismus Specialist | 036082457 | ILLINOIS | No |
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 | 10601008 | OTHER | ILLINOIS | CAQH |
| 2 | 200871680C | OTHER | INDIANA | C-ORLAND PARK 200871680C |
| 3 | 205785 | OTHER | ILLINOIS | PTAN MEDICARE COOK COUNTY IL |
| 4 | 036082457 | MEDICAID | ILLINOIS | |
| 5 | 200871680B | OTHER | INDIANA | CHICAGO RIDGE LOC. 200871680B |
| 6 | M400068419 | OTHER | INDIANA | MEDICARE INDIVIDUAL PIN/PTAN: M400068419 |
| 7 | 01621679 | OTHER | ILLINOIS | BC/BS OF ILLINOIS |
| 8 | 1083684922 | OTHER | | GROUP NPI |
| 9 | 200155690 | OTHER | INDIANA | INDIVIDUAL LEGACY PROVIDER |
| 10 | 200871680A | OTHER | INDIANA | MUNSTER LOCATION 200871680A |
| 11 | 10601008 | OTHER | INDIANA | CAQH |
| 12 | 200155690 | OTHER | INDIANA | INDIANA MEDICAID |
| 13 | 253350 | OTHER | INDIANA | MEDICARE GROUP LEGACY LPI: 253350 |
| 14 | 180046211 | OTHER | ILLINOIS | MEDICARE RAILROAD |
| 15 | 200871680D | OTHER | INDIANA | HINSDALE LOCATION 200871680D |
| 16 | 205786 | OTHER | ILLINOIS | PTAN MEDICARE DUPAGE COUNTY IL |