Healthcare Provider Details

I. General information

NPI: 1720151152
Provider Name (Legal Business Name): RALPH JOHN GEBERT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 W PETERSON AVE STE 401
CHICAGO IL
60659
US

IV. Provider business mailing address

3500 W PETERSON AVE STE 401
CHICAGO IL
60659
US

V. Phone/Fax

Practice location:
  • Phone: 773-588-3090
  • Fax: 773-588-3210
Mailing address:
  • Phone: 773-588-3090
  • Fax: 773-588-3210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: