Healthcare Provider Details

I. General information

NPI: 1750466504
Provider Name (Legal Business Name): PAULINE PAKLA BUBANKO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N CEDAR RD UNIT A
NEW LENOX IL
60451-1272
US

IV. Provider business mailing address

1230 N CEDAR RD UNIT A
NEW LENOX IL
60451-1272
US

V. Phone/Fax

Practice location:
  • Phone: 815-485-6533
  • Fax: 815-485-6534
Mailing address:
  • Phone: 815-485-6533
  • Fax: 815-485-6534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: