Healthcare Provider Details

I. General information

NPI: 1750375622
Provider Name (Legal Business Name): SUN AE MA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 DEMPSTER ST SUITE 101
MORTON GROVE IL
60053-3014
US

IV. Provider business mailing address

5901 DEMPSTER ST SUITE 101
MORTON GROVE IL
60053-3014
US

V. Phone/Fax

Practice location:
  • Phone: 847-470-1115
  • Fax: 847-470-1141
Mailing address:
  • Phone: 847-470-1115
  • Fax: 847-470-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008065
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-008065
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046-008065
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: