=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679716161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY EYE SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2009
-----------------------------------------------------
Last Update Date | 08/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2880 N MILWAUKEE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-486-7661
-----------------------------------------------------
Fax | 773-486-2821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1219 LAURA LN
-----------------------------------------------------
City | WOODRIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60517-5063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-622-0709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LUIZA MARIA GHEORGHE -YOUSSEFI
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 312-622-0709
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046009906
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------