Provider Demographics
NPI:1578998936
Name:MILLER, KRYSTLE (OD)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:MILLER
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 1:4979 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532
Mailing Address - Country:US
Mailing Address - Phone:708-552-7429
Mailing Address - Fax:
Practice Address - Street 1:1318 S FINLEY RD
Practice Address - Street 2:APT 3N
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4316
Practice Address - Country:US
Practice Address - Phone:224-500-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-010696152W00000X
IL046010696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist