Provider Demographics
NPI:1043628423
Name:SMITH, CHASE
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 W WESLEY ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5118
Mailing Address - Country:US
Mailing Address - Phone:708-371-5160
Mailing Address - Fax:708-930-1844
Practice Address - Street 1:5553 127TH ST
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-1123
Practice Address - Country:US
Practice Address - Phone:708-371-5160
Practice Address - Fax:708-930-1844
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01004630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist