Provider Demographics
NPI:1821735218
Name:ROTH CRAIN, NATALIE A (OD)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:A
Last Name:ROTH CRAIN
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 1:6857 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4151
Mailing Address - Country:US
Mailing Address - Phone:773-767-5000
Mailing Address - Fax:773-767-5176
Practice Address - Street 1:6857 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4151
Practice Address - Country:US
Practice Address - Phone:773-767-5000
Practice Address - Fax:773-767-5176
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011655152W00000X
IL390200000X
IL046011655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program