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General NPI Number Information
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NPI Number | 1619522067
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Entity Type | Individual
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Provider Name | PRAVEEN JEYASEELAN MD
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Gender | Male
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Dates
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Enumeration Date | 08/02/2019
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Last Update Date | 04/28/2021
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Provider Practice Location Address
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Address Line | 333 E ONTARIO ST APT 3309B
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City | CHICAGO
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State | IL
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Zip | 60611-8401
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Country | US
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Telephone | 443-962-5153
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Fax |
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Provider Business Mailing Address
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Address Line | 333 E ONTARIO ST APT 3309B
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City | CHICAGO
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State | IL
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Zip | 60611-8401
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Country | US
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Telephone | 443-962-5153
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207WX0109X
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Taxonomy Name | Neuro-ophthalmology Physician
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License Number | ME148721
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License Number State | FL
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