Provider Demographics
NPI:1386055762
Name:EDMISTON, ANNA MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:ANNA
Middle Name:MICHELLE
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N MILWAUKEE AVE STE L
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-8563
Mailing Address - Country:US
Mailing Address - Phone:847-356-0700
Mailing Address - Fax:
Practice Address - Street 1:300 N MILWAUKEE AVE STE L
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-356-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.146283207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.146283OtherILLINOIS LICENSE