Provider Demographics
NPI:1285818120
Name:ERNEST I. WATANABE, O.D. LTD.
Entity type:Organization
Organization Name:ERNEST I. WATANABE, O.D. LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:ISAMU
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-465-6660
Mailing Address - Street 1:1108 W GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2013
Mailing Address - Country:US
Mailing Address - Phone:773-465-6660
Mailing Address - Fax:773-274-8222
Practice Address - Street 1:1108 W GRANVILLE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2013
Practice Address - Country:US
Practice Address - Phone:773-465-6660
Practice Address - Fax:773-274-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006692261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046006692OtherIL STATE LICENSE
1053488569OtherINDIVIDUAL NPI #
1053488569OtherINDIVIDUAL NPI #
IL900840Medicare PIN
IL12019Medicare UPIN