MEDICARE: NICOLE KATSEVMAN OD

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	046011805	IL

General Provider Information

NPI Number	:	1609657030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE KATSEVMAN OD

Provider Business Mailing Address
First Line	:	3539 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-6447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3539 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-6447
Country	:	US
Telephone Number	:	312-929-3720
Fax Number	:

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

Provider Enumeration Date	:	10/11/2023
Last Update Date	:	10/11/2023

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