Provider Demographics
NPI:1154770501
Name:LA ROSA, CRISTINA (OD)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:LA ROSA
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 1:1618 S HALSTED ST
Mailing Address - Street 2:#5A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-7507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 5210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist