Individual
TRAVIS PARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
1756 W DIVISION ST, CHICAGO, IL 60622-7585
(773) 489-4848
(773) 489-0808
Mailing address
1756 W DIVISION ST, CHICAGO, IL 60622-7585
(773) 489-4848
(773) 489-4848
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046010179
IL
152W00000X
Optometrist
13586
CA
Other
Enumeration date
08/03/2008
Last updated
04/19/2012
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