Healthcare Provider Details

I. General information

NPI: 1033417845
Provider Name (Legal Business Name): DONALD V MADUZIA OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 RAILROAD AVE
CLARENDON HILLS IL
60514-1301
US

IV. Provider business mailing address

203 RAILROAD AVE
CLARENDON HILLS IL
60514-1301
US

V. Phone/Fax

Practice location:
  • Phone: 630-323-3202
  • Fax: 630-321-0512
Mailing address:
  • Phone: 630-323-3202
  • Fax: 630-321-0512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-007789
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number046.007789
License Number StateIL

VIII. Authorized Official

Name: DR. DONALD V. MADUZIA
Title or Position: OPTOMETRIST/PRESIDENT
Credential: O.D.
Phone: 630-323-3202