Provider Demographics
NPI:1356332423
Name:LERDVORATAVEE, VASANA (OD)
Entity Type:Individual
Prefix:DR
First Name:VASANA
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 1:1335 DOUGLAS RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-1634
Mailing Address - Country:US
Mailing Address - Phone:630-844-0908
Mailing Address - Fax:630-844-0677
Practice Address - Street 1:1335 DOUGLAS RD
Practice Address - Street 2:SUITE E
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-1634
Practice Address - Country:US
Practice Address - Phone:630-844-0908
Practice Address - Fax:630-844-0677
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X, 152WC0802X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL88337Medicare ID - Type Unspecified
ILU82948Medicare UPIN