Provider Demographics
NPI:1346230604
Name:LERDVORATAVEE, CHULA (OD)
Entity Type:Individual
Prefix:DR
First Name:CHULA
Middle Name:
Last Name:LERDVORATAVEE
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 1:2075 WIESBROOK RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-8312
Mailing Address - Country:US
Mailing Address - Phone:630-844-0908
Mailing Address - Fax:630-844-0677
Practice Address - Street 1:2075 WIESBROOK RD
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-8312
Practice Address - Country:US
Practice Address - Phone:630-844-0908
Practice Address - Fax:630-844-0677
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007841152WL0500X, 152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU24506Medicare UPIN
ILL18415Medicare ID - Type Unspecified