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General NPI Number Information
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NPI Number | 1750546339
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Entity Type | Organization
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Legal Business Name | OPTIMUM VISION INC
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Dates
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Enumeration Date | 07/23/2008
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Last Update Date | 07/23/2008
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Provider Practice Location Address
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Address Line | 7257 S JEFFERY BLVD
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City | CHICAGO
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State | IL
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Zip | 60649-3014
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Country | US
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Telephone | 773-752-3900
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Fax | 773-493-8837
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Provider Business Mailing Address
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Address Line | 7257 S JEFFERY BLVD
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City | CHICAGO
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State | IL
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Zip | 60649-3014
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Country | US
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Telephone | 773-752-3900
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Fax | 773-493-8837
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. DONNA JOHNSON
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Credential | MD
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Telephone | 773-752-3900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 036055856
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License Number State | IL
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