Provider Demographics
NPI:1194094466
Name:JOSEPH, JAIME (OD)
Entity type:Individual
Prefix:MISS
First Name:JAIME
Middle Name:
Last Name:JOSEPH
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 1:3914 W CORNELIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5006
Mailing Address - Country:US
Mailing Address - Phone:773-931-4427
Mailing Address - Fax:
Practice Address - Street 1:3914 W CORNELIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5006
Practice Address - Country:US
Practice Address - Phone:773-931-4427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010523152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist