Healthcare Provider Details

I. General information

NPI: 1063082519
Provider Name (Legal Business Name): SMRITI JAIN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 S KEDZIE AVE
MERRIONETTE PARK IL
60803-6307
US

IV. Provider business mailing address

14320 OAKWOOD CT
ORLAND PARK IL
60462-0014
US

V. Phone/Fax

Practice location:
  • Phone: 708-388-4400
  • Fax: 708-798-6790
Mailing address:
  • Phone: 708-314-5350
  • Fax: 708-288-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011524
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: