Basic Information
| Provider Information | |||||||||
| NPI: | 1821016981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 244 MOFFETT RD | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474821330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1211 S ARLINGTON HEIGHTS RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600053142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472592777 | ||||||||
| FaxNumber: | 8474376841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046-008692 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 180019824 | 01 | IL | MEDICARE RAILROAD RETIREM | OTHER |