Provider Demographics
NPI:1821206384
Name:WINTERBOTHAM, C. T (MD)
Entity Type:Individual
Prefix:DR
First Name:C.
Middle Name:T
Last Name:WINTERBOTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHLOE
Other - Middle Name:TYLER
Other - Last Name:WINTERBOTHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1855 WEST TAYLOR STREET
Mailing Address - Street 2:SUITE 3.138
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7243
Mailing Address - Country:US
Mailing Address - Phone:312-996-6590
Mailing Address - Fax:312-996-7770
Practice Address - Street 1:1855 W TAYLOR ST
Practice Address - Street 2:SUITE 3.138
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7242
Practice Address - Country:US
Practice Address - Phone:312-996-6590
Practice Address - Fax:312-996-7770
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD13706Medicare UPIN
ILP02516Medicare ID - Type Unspecified