MEDICARE: DR. ROGER BLANK 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	046-007466	IL

General Provider Information

NPI Number	:	1578619391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER BLANK O.D.

Provider Business Mailing Address
First Line	:	603 CORTLAND DR
Second Line	:
City	:	LAKE ZURICH
State	:	IL
Zip	:	60047-2366
Country	:	US
Telephone Number	:	847-975-1653
Fax Number	:

Provider Business Practice Location Address
First Line	:	603 CORTLAND DR
Second Line	:
City	:	LAKE ZURICH
State	:	IL
Zip	:	60047-2366
Country	:	US
Telephone Number	:	847-975-1653
Fax Number	:

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

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	03/22/2022

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