Provider Demographics
NPI:1487605762
Name:EIDE, TERESA BETH (OD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:BETH
Last Name:EIDE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:BETH
Other - Last Name:CARSTENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1423 W FILLMORE ST # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4615
Mailing Address - Country:US
Mailing Address - Phone:773-321-6668
Mailing Address - Fax:
Practice Address - Street 1:122 BROADVIEW VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-4874
Practice Address - Country:US
Practice Address - Phone:708-343-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD591152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9201274Medicaid
SD9201274Medicaid
U90972Medicare UPIN