Healthcare Provider Details

I. General information

NPI: 1346760725
Provider Name (Legal Business Name): DENISE D SKIADOPOULOS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 S MICHIGAN AVE
CHICAGO IL
60616
US

IV. Provider business mailing address

3241 S MICHIGAN AVE
CHICAGO IL
60616-4201
US

V. Phone/Fax

Practice location:
  • Phone: 312-949-7751
  • Fax:
Mailing address:
  • Phone: 312-949-7751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008580-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberTUV008580-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011182
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: