Provider Demographics
NPI:1962492975
Name:NIELSEN, CHARLOTTE FLORENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:FLORENCE
Last Name:NIELSEN
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 1:1120 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7960
Mailing Address - Country:US
Mailing Address - Phone:847-223-2000
Mailing Address - Fax:847-223-9400
Practice Address - Street 1:1120 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-7960
Practice Address - Country:US
Practice Address - Phone:847-223-2000
Practice Address - Fax:847-223-9400
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008590152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008590Medicaid
IL1033303169OtherCORPORATE NPI
IL1033303169OtherCORPORATE NPI
IL046008590Medicaid
IL1191910001Medicare NSC