MEDICARE: JULLIAN CERASUOLO

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046011300	IL

General Provider Information

NPI Number	:	1508424136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULLIAN CERASUOLO

Provider Business Mailing Address
First Line	:	1140 N WELLS ST UNIT 604
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-3068
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1123 N STATE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-2717
Country	:	US
Telephone Number	:	312-878-2028
Fax Number	:

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

Provider Enumeration Date	:	05/29/2019
Last Update Date	:	05/29/2019

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Directions to “ JULLIAN CERASUOLO ” Practice Location

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