Provider Demographics
NPI:1790982601
Name:SIRITHAVEE, TANAPOL (OD)
Entity Type:Individual
Prefix:DR
First Name:TANAPOL
Middle Name:
Last Name:SIRITHAVEE
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 1:1400 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-3232
Mailing Address - Country:US
Mailing Address - Phone:773-640-5384
Mailing Address - Fax:
Practice Address - Street 1:1400 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3232
Practice Address - Country:US
Practice Address - Phone:773-640-5384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46009972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist