Healthcare Provider Details

I. General information

NPI: 1497287148
Provider Name (Legal Business Name): EMA AVDAGIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 10/26/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE FL 5
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

922 W WASHINTON BLVD UNIT 916
CHICAGO IL
60607
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-8000
  • Fax:
Mailing address:
  • Phone: 646-943-2886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036161226
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: