Provider Demographics
NPI:1144843525
Name:PANTOJA, PAIGE PAULAS (OD)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:PAULAS
Last Name:PANTOJA
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 1:525 W TOWN CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1248
Mailing Address - Country:US
Mailing Address - Phone:217-531-5393
Mailing Address - Fax:
Practice Address - Street 1:525 W TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1248
Practice Address - Country:US
Practice Address - Phone:217-531-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011726152W00000X, 152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program