Provider Demographics
NPI:1083677504
Name:PIETRZYK, CHRISTA D (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:D
Last Name:PIETRZYK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 W NORTH ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-8201
Mailing Address - Country:US
Mailing Address - Phone:815-478-0100
Mailing Address - Fax:815-478-9100
Practice Address - Street 1:540 W NORTH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-8201
Practice Address - Country:US
Practice Address - Phone:815-478-0100
Practice Address - Fax:815-478-9100
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009719Medicaid
IL046009719Medicaid
ILK23344Medicare UPIN