Provider Demographics
NPI:1093190019
Name:KOUTNIK, CASSANDRA ANNE (OD)
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:ANNE
Last Name:KOUTNIK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:CASSANDRA
Other - Middle Name:ANNE
Other - Last Name:WEINFURTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2121 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2948
Mailing Address - Country:US
Mailing Address - Phone:773-697-7370
Mailing Address - Fax:
Practice Address - Street 1:2121 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2948
Practice Address - Country:US
Practice Address - Phone:773-697-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist