Provider Demographics
NPI:1427165885
Name:PITRA, ANNMARIE (OD)
Entity type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:
Last Name:PITRA
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 1:1712 OGDEN AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1230
Mailing Address - Country:US
Mailing Address - Phone:630-541-3169
Mailing Address - Fax:630-541-3847
Practice Address - Street 1:1712 OGDEN AVE STE D
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1230
Practice Address - Country:US
Practice Address - Phone:630-541-3169
Practice Address - Fax:630-541-3847
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU62851Medicare UPIN