Provider Demographics
NPI:1053488569
Name:WATANABE, ERNEST ISAMU (OD)
Entity Type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:ISAMU
Last Name:WATANABE
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 1:1108 W GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2013
Mailing Address - Country:US
Mailing Address - Phone:773-465-6660
Mailing Address - Fax:773-274-8222
Practice Address - Street 1:1108 W GRANVILLE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2013
Practice Address - Country:US
Practice Address - Phone:773-465-6660
Practice Address - Fax:773-274-8222
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2023-03-07
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
ILMWO224105OtherDEA
IL900840Medicare ID - Type Unspecified
ILU12019Medicare UPIN
ILMWO224105OtherDEA