MEDICARE: MR. ALBERTO ANTMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

General Provider Information

NPI Number	:	1053319772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALBERTO ANTMAN

Provider Business Mailing Address
First Line	:	120 SKOKIE BLVD
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-3050
Country	:	US
Telephone Number	:	847-251-3330
Fax Number	:	847-251-9580

Provider Business Practice Location Address
First Line	:	120 SKOKIE BLVD
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-3050
Country	:	US
Telephone Number	:	847-251-3330
Fax Number	:	847-251-9580

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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