Provider Demographics
NPI:1811969512
Name:CRAWFORD, CONNIE JEAN (OD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:JEAN
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:JEAN
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:395 CAPITAL LN
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-4496
Mailing Address - Country:US
Mailing Address - Phone:847-548-9077
Mailing Address - Fax:
Practice Address - Street 1:884 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-1226
Practice Address - Country:US
Practice Address - Phone:847-395-4090
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-0079136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT39099Medicare UPIN
ILL76090Medicare ID - Type Unspecified