Healthcare Provider Details

I. General information

NPI: 1033385141
Provider Name (Legal Business Name): ANTIOCH EYE ASSOCIATES OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

884 HILLSIDE AVE
ANTIOCH IL
60002-1226
US

IV. Provider business mailing address

884 HILLSIDE AVE
ANTIOCH IL
60002-1226
US

V. Phone/Fax

Practice location:
  • Phone: 847-395-4090
  • Fax: 847-395-7378
Mailing address:
  • Phone: 847-395-4090
  • Fax: 847-395-7378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009062
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007913
License Number StateIL

VIII. Authorized Official

Name: DR. CONNIE J CRAWFROD
Title or Position: OWNER
Credential: O.D.
Phone: 847-395-4090