Healthcare Provider Details

I. General information

NPI: 1902899313
Provider Name (Legal Business Name): DOMINICK M MAINO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/03/2007
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: 312-949-7660
Mailing address:
  • Phone: 312-949-7280
  • Fax: 312-949-7668

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: