MEDICARE: DR. VASANA LERDVORATAVEE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	152W00000X	Optometrist	IL
2	152WC0802X	Corneal and Contact Management Optometrist	IL
3	152WV0400X	Vision Therapy Optometrist	IL

General Provider Information

NPI Number	:	1356332423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VASANA LERDVORATAVEE O.D.

Provider Business Mailing Address
First Line	:	1335 DOUGLAS RD
Second Line	:	SUITE E
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1634
Country	:	US
Telephone Number	:	630-844-0908
Fax Number	:	630-844-0677

Provider Business Practice Location Address
First Line	:	1335 DOUGLAS RD
Second Line	:	SUITE E
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1634
Country	:	US
Telephone Number	:	630-844-0908
Fax Number	:	630-844-0677

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	09/11/2025

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