Provider Demographics
NPI:1598864324
Name:DR ATHA HYDERI PC
Entity Type:Organization
Organization Name:DR ATHA HYDERI PC
Other - Org Name:PRIMARY VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ATHA
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:HYDERI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-351-0085
Mailing Address - Street 1:833 N ROSELLE RD
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-4212
Mailing Address - Country:US
Mailing Address - Phone:630-351-0085
Mailing Address - Fax:630-351-1530
Practice Address - Street 1:833 N ROSELLE RD
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-4212
Practice Address - Country:US
Practice Address - Phone:630-351-0085
Practice Address - Fax:630-351-1530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
208083Medicare UPIN