Healthcare Provider Details

I. General information

NPI: 1093854820
Provider Name (Legal Business Name): CENTER FOR SIGHT OF CENTRAL ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 N ROUTE 121
DECATUR IL
62526-9461
US

IV. Provider business mailing address

2442 N ROUTE 121
DECATUR IL
62526-9461
US

V. Phone/Fax

Practice location:
  • Phone: 217-233-3101
  • Fax: 217-233-3107
Mailing address:
  • Phone: 217-233-3101
  • Fax: 217-233-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009767
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number036069820
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number036069820
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036069820
License Number StateIL

VIII. Authorized Official

Name: DR. MARCUS S DERANIAN
Title or Position: OWNER
Credential: MD
Phone: 217-233-3101