Provider Demographics
NPI:1932288198
Name:CHARLES S KEFALAS ODPC
Entity Type:Organization
Organization Name:CHARLES S KEFALAS ODPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:KEFALAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-582-0660
Mailing Address - Street 1:4256 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5037
Mailing Address - Country:US
Mailing Address - Phone:773-582-0660
Mailing Address - Fax:773-582-0859
Practice Address - Street 1:4256 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5037
Practice Address - Country:US
Practice Address - Phone:773-582-0660
Practice Address - Fax:773-582-0859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDB5027Medicare PIN
IL625490Medicare PIN
IL4259410001Medicare NSC