=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265634810
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAMRAN HUSSAIN O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2007
-----------------------------------------------------
Last Update Date | 05/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 635 CHICAGO AVE
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-2365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-901-0781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3429 RIVERSIDE DR
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-1061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-452-5811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046009594
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------