Provider Demographics
NPI:1780634980
Name:RAZVI, SAMEENA NAZ (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMEENA
Middle Name:NAZ
Last Name:RAZVI
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 1:5527 35TH ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4807
Mailing Address - Country:US
Mailing Address - Phone:802-999-1028
Mailing Address - Fax:
Practice Address - Street 1:6641 GRAND AVE STE D
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5262
Practice Address - Country:US
Practice Address - Phone:847-856-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46010019152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012551Medicaid
VT1012551Medicaid