Healthcare Provider Details

I. General information

NPI: 1487605762
Provider Name (Legal Business Name): TERESA BETH EIDE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA BETH CARSTENSEN O.D.

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 BROADVIEW VILLAGE SQ
BROADVIEW IL
60155-4874
US

IV. Provider business mailing address

1423 W FILLMORE ST # 2
CHICAGO IL
60607-4615
US

V. Phone/Fax

Practice location:
  • Phone: 708-343-2099
  • Fax:
Mailing address:
  • Phone: 773-321-6668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number591
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: