MEDICARE: OPTIMUM VISION INC

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	036055856	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	18175	OTHER		DAVIS EYE VISION
2	921513	OTHER		BLOCK VISION
3	919248	OTHER	IL	EYE MED

General Provider Information

NPI Number	:	1750546339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM VISION INC

Provider Business Mailing Address
First Line	:	7257 S JEFFERY BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3014
Country	:	US
Telephone Number	:	773-752-3900
Fax Number	:	773-493-8837

Provider Business Practice Location Address
First Line	:	7257 S JEFFERY BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3014
Country	:	US
Telephone Number	:	773-752-3900
Fax Number	:	773-493-8837

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. DONNA JOHNSON
Credential	:	MD
Telephone Number	:	773-752-3900

Provider Enumeration Date	:	07/23/2008
Last Update Date	:	07/23/2008

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Directions to “OPTIMUM VISION INC ” Practice Location

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