Healthcare Provider Details

I. General information

NPI: 1134579808
Provider Name (Legal Business Name): ANGELA KUMAR O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2852 N HALSTED ST
CHICAGO IL
60657-6531
US

IV. Provider business mailing address

2852 N HALSTED ST
CHICAGO IL
60657-6531
US

V. Phone/Fax

Practice location:
  • Phone: 773-549-1111
  • Fax:
Mailing address:
  • Phone: 773-549-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010992
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: