Healthcare Provider Details

I. General information

NPI: 1750390860
Provider Name (Legal Business Name): EUGENE PAUL ERTMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W NORTH AVE OPTOMETRIST'S OFFICE
CHICAGO IL
60639-4611
US

IV. Provider business mailing address

7314 N KILDARE AVE
LINCOLNWOOD IL
60712-1918
US

V. Phone/Fax

Practice location:
  • Phone: 773-252-8152
  • Fax: 773-252-8278
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: