Provider Demographics
NPI:1558313189
Name:OVITSKY, CHARLES S (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:OVITSKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 W PETERSON AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3306
Mailing Address - Country:US
Mailing Address - Phone:773-588-3090
Mailing Address - Fax:773-588-3210
Practice Address - Street 1:3500 W PETERSON AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3306
Practice Address - Country:US
Practice Address - Phone:773-588-3090
Practice Address - Fax:773-588-3210
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007650152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007650Medicaid
410022813OtherRAILROAD MEDICARE
P01107046OtherRAIL ROAD MEDICARE
IL0001604768OtherBLUE CROSS BLUE SHIELD
MO310055007Medicaid
IL7060001Medicare PIN
IL0001604768OtherBLUE CROSS BLUE SHIELD
P01107046OtherRAIL ROAD MEDICARE
410022813OtherRAILROAD MEDICARE
IL7058001Medicare PIN