Healthcare Provider Details

I. General information

NPI: 1699121194
Provider Name (Legal Business Name): KYLE COX BLAIR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2454 E DEMPSTER ST STE 400
DES PLAINES IL
60016-5320
US

IV. Provider business mailing address

2454 E DEMPSTER ST STE 400
DES PLAINES IL
60016-5320
US

V. Phone/Fax

Practice location:
  • Phone: 847-299-0700
  • Fax: 847-390-0616
Mailing address:
  • Phone: 541-990-5464
  • Fax: 847-390-0616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036.159412
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number036.159412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: