Healthcare Provider Details

I. General information

NPI: 1235210964
Provider Name (Legal Business Name): COLBY LEE CARTER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7317 W 25TH ST
NORTH RIVERSIDE IL
60546-1409
US

IV. Provider business mailing address

3457 N LINCOLN AVE # 3
CHICAGO IL
60657-1101
US

V. Phone/Fax

Practice location:
  • Phone: 708-442-8899
  • Fax: 708-442-9466
Mailing address:
  • Phone: 312-731-2621
  • Fax: 708-442-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: