=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033725114
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SABRINA D'HAITI OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2020
-----------------------------------------------------
Last Update Date | 03/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 635 CHICAGO AVE
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-2365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-864-8209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 OLD GALLOWS RD STE 520
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-3970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-847-8899
-----------------------------------------------------
Fax | 571-223-6780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046.011473
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------