Provider Demographics
NPI:1124009162
Name:RADFORD, SASHA L (OD)
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:L
Last Name:RADFORD
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 1:320 N LADD ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-1612
Mailing Address - Country:US
Mailing Address - Phone:815-842-4304
Mailing Address - Fax:
Practice Address - Street 1:320 N LADD ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-1612
Practice Address - Country:US
Practice Address - Phone:815-842-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010421152W00000X, 152W00000X
IN18003221A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYV04251Medicare UPIN