Provider Demographics
NPI:1396894663
Name:AMIN, KHYATI (OD)
Entity type:Individual
Prefix:
First Name:KHYATI
Middle Name:
Last Name:AMIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KHYATI
Other - Middle Name:
Other - Last Name:MODI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8066 CHESTERTON DR
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-8010
Mailing Address - Country:US
Mailing Address - Phone:630-910-8384
Mailing Address - Fax:
Practice Address - Street 1:3800 E MAIN ST
Practice Address - Street 2:#114
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2457
Practice Address - Country:US
Practice Address - Phone:630-443-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009760152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21163Medicare ID - Type Unspecified
ILV06698Medicare UPIN