Provider Demographics
NPI:1356891022
Name:COLLISON, FREDERICK T (OD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:T
Last Name:COLLISON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:
Other - Last Name:COLLISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3450 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5430
Mailing Address - Country:US
Mailing Address - Phone:630-743-4500
Mailing Address - Fax:630-743-4537
Practice Address - Street 1:3450 LACEY RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5430
Practice Address - Country:US
Practice Address - Phone:630-743-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046.010506OtherOPTOMETRY LICENSE
IL346.003257OtherLICENSED OPTOMETRIST CONTROLLED SUBSTANCE LICENSE