Provider Demographics
NPI:1477703411
Name:CHRISTINA J. LEVI O D P C
Entity Type:Organization
Organization Name:CHRISTINA J. LEVI O D P C
Other - Org Name:EDWARDSVILLE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEVI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-656-8888
Mailing Address - Street 1:2100 TROY RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2595
Mailing Address - Country:US
Mailing Address - Phone:618-656-8888
Mailing Address - Fax:618-656-8920
Practice Address - Street 1:2100 TROY RD
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2595
Practice Address - Country:US
Practice Address - Phone:618-656-8888
Practice Address - Fax:618-656-8920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010111152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0460100111Medicaid
MO1184886731Medicaid