Provider Demographics
NPI:1033225743
Name:CRUMBLISS, CASEY JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:JAMES
Last Name:CRUMBLISS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3539 N SOUTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6447
Mailing Address - Country:US
Mailing Address - Phone:773-871-2020
Mailing Address - Fax:773-871-2099
Practice Address - Street 1:3539 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6447
Practice Address - Country:US
Practice Address - Phone:773-871-2020
Practice Address - Fax:773-871-2099
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U96237Medicare UPIN