Healthcare Provider Details

I. General information

NPI: 1619376571
Provider Name (Legal Business Name): ADA AVARY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2014
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 STRATFORD PL STE C-15
BLOOMINGDALE IL
60108-2655
US

IV. Provider business mailing address

3400 W STONEGATE BLVD APT 316
ARLINGTON HEIGHTS IL
60005-1065
US

V. Phone/Fax

Practice location:
  • Phone: 630-295-8031
  • Fax:
Mailing address:
  • Phone: 703-401-2957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010815
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046010815
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number046010815
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: