Provider Demographics
NPI:1164664280
Name:ERIC TSENG O.D., PROF. CORP.
Entity Type:Organization
Organization Name:ERIC TSENG O.D., PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:TSENG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-303-8279
Mailing Address - Street 1:9934 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1831
Mailing Address - Country:US
Mailing Address - Phone:773-303-8279
Mailing Address - Fax:773-681-7119
Practice Address - Street 1:9934 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1831
Practice Address - Country:US
Practice Address - Phone:773-303-8279
Practice Address - Fax:773-681-7119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010071Medicaid
IL1629233580Medicaid
ILIL2815OtherPTAN
ILIL2815Medicare PIN