Provider Demographics
NPI:1962528372
Name:CARRILLO, TEODORO (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:TEODORO
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2008
Mailing Address - Country:US
Mailing Address - Phone:773-561-0870
Mailing Address - Fax:773-561-4185
Practice Address - Street 1:4610 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2008
Practice Address - Country:US
Practice Address - Phone:773-561-0870
Practice Address - Fax:773-561-4185
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2511-5278156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician