Provider Demographics
NPI:1952406787
Name:VIZE, KATHLEEN (OD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:VIZE
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 1:1505 EASTLAND DR STE 2200
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7910
Mailing Address - Country:US
Mailing Address - Phone:309-662-7700
Mailing Address - Fax:309-662-0829
Practice Address - Street 1:1505 EASTLAND DR STE 2200
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7910
Practice Address - Country:US
Practice Address - Phone:309-662-7700
Practice Address - Fax:309-662-0829
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2426152W00000X
AZ002480152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU92629Medicare UPIN