Provider Demographics
NPI:1376799288
Name:BARBARO, KRISTIE JO (OD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:JO
Last Name:BARBARO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:KRISTIE
Other - Middle Name:JO
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:675 N SAINT CLAIR ST
Mailing Address - Street 2:15TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5975
Mailing Address - Country:US
Mailing Address - Phone:312-695-8150
Mailing Address - Fax:312-695-3652
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:15TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-8150
Practice Address - Fax:312-695-3652
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3112-35152W00000X
IL046-010316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000547354OtherMEDICARE PTAN