Healthcare Provider Details

I. General information

NPI: 1639105273
Provider Name (Legal Business Name): DOMINICK LOUIS OPITZ O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 S MICHIGAN AVE
CHICAGO IL
60616-3849
US

IV. Provider business mailing address

3241 S MICHIGAN AVE
CHICAGO IL
60616-3849
US

V. Phone/Fax

Practice location:
  • Phone: 312-225-6200
  • Fax: 312-949-7706
Mailing address:
  • Phone: 312-225-6200
  • Fax: 312-949-7706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008976
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: