Healthcare Provider Details

I. General information

NPI: 1740305366
Provider Name (Legal Business Name): ANTHONY PETE TSIFTILIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2127 MIDLANDS CT. UNIT 101
SYCAMORE IL
60178
US

IV. Provider business mailing address

178 QUINLAN AVE
DEKALB IL
60115-8209
US

V. Phone/Fax

Practice location:
  • Phone: 815-756-4244
  • Fax:
Mailing address:
  • Phone: 815-739-5709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-008933
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046-008933
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number046-008933
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number046-008933
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number046-008933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: