Provider Demographics
NPI:1740361443
Name:CARMINE, TERRANCE PETER (OD)
Entity type:Individual
Prefix:DR
First Name:TERRANCE
Middle Name:PETER
Last Name:CARMINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-3129
Mailing Address - Country:US
Mailing Address - Phone:708-895-4422
Mailing Address - Fax:708-895-4482
Practice Address - Street 1:3224 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-3129
Practice Address - Country:US
Practice Address - Phone:708-895-4422
Practice Address - Fax:708-895-4482
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-6715152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410033967Medicare PIN
IL0532300001Medicare NSC
ILT36694Medicare UPIN