Healthcare Provider Details

I. General information

NPI: 1871041756
Provider Name (Legal Business Name): EYE PHYSICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 N MICHIGAN AVE
CHICAGO IL
60611-2203
US

IV. Provider business mailing address

PO BOX 6476
CHICAGO IL
60680-6476
US

V. Phone/Fax

Practice location:
  • Phone: 312-397-0403
  • Fax: 312-397-0390
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARITA SMITH
Title or Position: OPTOMETRIST
Credential:
Phone: 312-397-0403