Provider Demographics
NPI:1104388800
Name:REED, TESIA (OD)
Entity Type:Individual
Prefix:
First Name:TESIA
Middle Name:
Last Name:REED
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TESIA
Other - Middle Name:
Other - Last Name:WYSZOMIRSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-306-9001
Practice Address - Street 1:1469 STARFISH LN
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-8621
Practice Address - Country:US
Practice Address - Phone:773-968-2152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002688152W00000X
MTOPT-OPT-LIC-3977152W00000X
PAOEG004021152W00000X
WI3890-35152W00000X
IL046-011470152W00000X
FLTPOP67152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046011470Medicaid