Provider Demographics
NPI:1528636198
Name:TRAN, RAPHAELLA (OD, MS)
Entity type:Individual
Prefix:
First Name:RAPHAELLA
Middle Name:
Last Name:TRAN
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:62002-6241
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:314-741-4947
Practice Address - Street 1:360 S WAUKEGAN RD STE A
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5654
Practice Address - Country:US
Practice Address - Phone:847-412-0311
Practice Address - Fax:847-412-0316
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist