Provider Demographics
NPI:1558673921
Name:CARRILLO-OWEN, DESIREE VICTORIA (OD)
Entity Type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:VICTORIA
Last Name:CARRILLO-OWEN
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 1:5455 HARRISON PARK LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-2245
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:2914 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1237
Practice Address - Country:US
Practice Address - Phone:847-864-4768
Practice Address - Fax:847-864-4795
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL579250113Medicare PIN
IL908081002Medicare PIN