Provider Demographics
NPI:1558880633
Name:TAHVILIAN, MARNI HARRIS (OD)
Entity type:Individual
Prefix:DR
First Name:MARNI
Middle Name:HARRIS
Last Name:TAHVILIAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARNI
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2015 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3190
Mailing Address - Country:US
Mailing Address - Phone:630-668-8250
Mailing Address - Fax:630-668-8916
Practice Address - Street 1:2015 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3190
Practice Address - Country:US
Practice Address - Phone:630-634-2771
Practice Address - Fax:630-221-0019
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-011195152W00000X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046-011195Medicaid