Provider Demographics
NPI:1619950151
Name:CULLEN-REGAN, MARGARET (OD)
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:
Last Name:CULLEN-REGAN
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 1:9501 171ST ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-6110
Mailing Address - Country:US
Mailing Address - Phone:708-403-8300
Mailing Address - Fax:708-403-8333
Practice Address - Street 1:9501 171ST ST
Practice Address - Street 2:SUITE C
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-6110
Practice Address - Country:US
Practice Address - Phone:708-403-8300
Practice Address - Fax:708-403-8333
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008012152WC0802X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU40395Medicare UPIN
K03667Medicare ID - Type Unspecified