Basic Information
| Provider Information | |||||||||
| NPI: | 1033261904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTINA J. LEVI O D,P C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EDWARDSVILLE VISION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 TROY RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620252595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186568888 | ||||||||
| FaxNumber: | 6186568920 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 TROY RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620252595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186568888 | ||||||||
| FaxNumber: | 6186568920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEVI | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6186568888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 29111 | 01 | SPECTERA | OTHER |