Basic Information
| Provider Information | |||||||||
| NPI: | 1801883004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHEATON EYE CLINIC LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2015 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601873152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306688250 | ||||||||
| FaxNumber: | 6306688916 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601873152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306688250 | ||||||||
| FaxNumber: | 6306688916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6305883630 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | CB4564 | 01 | IL | RAILROAD MEDICARE | OTHER | 0800326 | 01 | IL | UNITED HEALTHCARE | OTHER | 02215844 | 01 | IL | BCBS | OTHER | 8254738 | 01 | IL | AETNA | OTHER |