=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427165885
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNMARIE PITRA OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 05/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1712 OGDEN AVE STE D
-----------------------------------------------------
City | LISLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60532-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-541-3169
-----------------------------------------------------
Fax | 630-541-3847
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1712 OGDEN AVE STE D
-----------------------------------------------------
City | LISLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60532-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-541-3169
-----------------------------------------------------
Fax | 630-541-3847
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046008824
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------