Healthcare Provider Details

I. General information

NPI: 1497945430
Provider Name (Legal Business Name): ALLEN BRUCE SIMON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4709 GOLF RD TOWER 2 12TH FL MYERS WYSE CENTER FOR THE EYE
SKOKIE IL
60076
US

IV. Provider business mailing address

4709 GOLF RD TOWER 2 12TH FL MYERS WYSE CENTER FOR THE EYE
SKOKIE IL
60076
US

V. Phone/Fax

Practice location:
  • Phone: 847-328-2020
  • Fax: 847-328-0523
Mailing address:
  • Phone: 847-328-2020
  • Fax: 847-328-0523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: