Provider Demographics
NPI:1952423139
Name:FAHY, TIMOTHY J (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:FAHY
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 1:5943 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1629
Mailing Address - Country:US
Mailing Address - Phone:773-685-0363
Mailing Address - Fax:773-685-0944
Practice Address - Street 1:5943 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-1629
Practice Address - Country:US
Practice Address - Phone:773-685-0363
Practice Address - Fax:773-685-0944
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007793152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
IL046007793152WX0102X, 152WL0500X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU30456Medicare UPIN
IL973880Medicare ID - Type Unspecified