Basic Information
| Provider Information | |||||||||
| NPI: | 1750375622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | SUN AE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 DEMPSTER ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MORTON GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600533014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474701115 | ||||||||
| FaxNumber: | 8474701141 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 DEMPSTER ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MORTON GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600533014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474701115 | ||||||||
| FaxNumber: | 8474701141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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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 | 046008065 | IL | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 046-008065 | IL | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | 046-008065 | IL | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
No ID Information.