Provider Demographics
NPI:1427749209
Name:YIFRU, AYHUBRHAN (OD)
Entity type:Individual
Prefix:
First Name:AYHUBRHAN
Middle Name:
Last Name:YIFRU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AYU
Other - Middle Name:
Other - Last Name:YIFRU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:111 E 4TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6206
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:
Practice Address - Street 1:1233 W MORTON AVE STE C
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2774
Practice Address - Country:US
Practice Address - Phone:217-245-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023029302152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist