MEDICARE: MICHAEL PASKVAN O.D.

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	152W00000X	Optometrist		IL

General Provider Information

NPI Number	:	1457400624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL PASKVAN O.D.

Provider Business Mailing Address
First Line	:	2800 N LAKE SHORE DR
Second Line	:	#3508
City	:	CHICAGO
State	:	IL
Zip	:	60657-6232
Country	:	US
Telephone Number	:	312-560-8003
Fax Number	:

Provider Business Practice Location Address
First Line	:	2736 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1503
Country	:	US
Telephone Number	:	773-248-8866
Fax Number	:

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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