Provider Demographics
NPI:1851341697
Name:DISALVOOST, CHRISTINE (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:DISALVOOST
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 1:10001 W 143RD ST
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2026
Mailing Address - Country:US
Mailing Address - Phone:708-349-2600
Mailing Address - Fax:708-349-9201
Practice Address - Street 1:10001 W 143RD ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2026
Practice Address - Country:US
Practice Address - Phone:708-349-2600
Practice Address - Fax:708-349-9201
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCN3870OtherRR MEDICARE GRP OL
IL0363241858OtherTAX ID OAK LAWN
IL0618250001OtherDME OAKLAWN
IL1148260001OtherDME ORLAND PARK
IL0363448367OtherTAX ID ORLAND PARK
IL508980OtherMEDICARE PROVIDER OL
IL0410017240OtherRR MEDICARE IND ORLAND
IL0990005851OtherRR MEDICARE IND.OAKLAWN
ILDA8522OtherRR MEDICARE GRP OP
IL985800OtherMEDICARE PROVIDER OP
ILDA8522OtherRR MEDICARE GRP OP
IL1148260001OtherDME ORLAND PARK
ILCN3870OtherRR MEDICARE GRP OL