Provider Demographics
NPI:1689617375
Name:HYDERI, ATHA ALI (OD)
Entity Type:Individual
Prefix:DR
First Name:ATHA
Middle Name:ALI
Last Name:HYDERI
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 1:833 N ROSELLE RD
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172
Mailing Address - Country:US
Mailing Address - Phone:630-660-5737
Mailing Address - Fax:
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
Practice Address - Country:US
Practice Address - Phone:630-660-5737
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208083Medicare UPIN
K03275Medicare ID - Type Unspecified