Provider Demographics
NPI:1992756290
Name:SYPHERD, CARRIE (OD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:SYPHERD
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 1:820 E TERRA COTTA AVE
Mailing Address - Street 2:SUITE 256
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3649
Mailing Address - Country:US
Mailing Address - Phone:815-455-2800
Mailing Address - Fax:815-455-2801
Practice Address - Street 1:820 E TERRA COTTA AVE
Practice Address - Street 2:SUITE 256
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3649
Practice Address - Country:US
Practice Address - Phone:815-455-2800
Practice Address - Fax:815-455-2801
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009482152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU92565Medicare UPIN
ILK18430Medicare PIN
IL211827Medicare PIN
ILIL 2605Medicare PIN
ILIL 2607Medicare PIN