Provider Demographics
NPI:1326308941
Name:DIANA L HASKINS
Entity Type:Organization
Organization Name:DIANA L HASKINS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-864-8209
Mailing Address - Street 1:635 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2365
Mailing Address - Country:US
Mailing Address - Phone:847-864-8209
Mailing Address - Fax:847-864-0058
Practice Address - Street 1:635 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2365
Practice Address - Country:US
Practice Address - Phone:847-864-8209
Practice Address - Fax:847-864-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008855152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL672040Medicare PIN