Basic Information
| Provider Information | |||||||||
| NPI: | 1598916041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RESULI | ||||||||
| FirstName: | ENEIDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAFEZI | ||||||||
| OtherFirstName: | ENEIDA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
| FaxNumber: | 3147414947 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 LAFAYETTE CTR | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630113943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363911309 | ||||||||
| FaxNumber: | 6363944892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2008019621 | MO | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.