Healthcare Provider Details

I. General information

NPI: 1760744825
Provider Name (Legal Business Name): ERIK J MOTHERSBAUGH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 S MICHIGAN AVE
CHICAGO IL
60616-3878
US

IV. Provider business mailing address

3241 S MICHIGAN AVE
CHICAGO IL
60616-3878
US

V. Phone/Fax

Practice location:
  • Phone: 312-225-6200
  • Fax: 312-949-7389
Mailing address:
  • Phone: 312-225-6200
  • Fax: 312-949-7389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: