Provider Demographics
NPI:1235201096
Name:CUCCIA-KAWAKAMI, TERESA L (OD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:CUCCIA-KAWAKAMI
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 1:127 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1262
Mailing Address - Country:US
Mailing Address - Phone:815-469-7598
Mailing Address - Fax:708-403-1739
Practice Address - Street 1:856 ORLAND SQUARE DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3223
Practice Address - Country:US
Practice Address - Phone:708-403-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL77676Medicare ID - Type Unspecified
ILU36134Medicare UPIN