Provider Demographics
NPI:1811949373
Name:HALL, DEBRA (OD)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:
Last Name:HALL
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 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:1200 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4437
Practice Address - Country:US
Practice Address - Phone:618-993-5686
Practice Address - Fax:618-997-6250
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009755152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009755Medicaid
IL0814870005OtherMEDICARE NSC NUMBER
IL0814870004OtherMEDICARE NSC NUMBER
IL0814870009OtherMEDICARE NSC NUMBER
410828OtherHARMONY HEALTH PLAN
ILP00260857, CA2196OtherMEDICARE RAILROAD
IL0814870001OtherMEDICARE NSC NUMBER
IL9755OtherEYEMED
IL0814870003OtherMEDICARE NSC NUMBER
107333OtherHEALTH ALLIANCE
ILV05898Medicare UPIN
107333OtherHEALTH ALLIANCE