Healthcare Provider Details

I. General information

NPI: 1871880112
Provider Name (Legal Business Name): ADULT AND PEDIATRIC EYE SPECIALISTS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 RIDGE RD SUITE #3
MUNSTER IN
46321-1643
US

IV. Provider business mailing address

9336 FALLING WATERS DR W
BURR RIDGE IL
60527-6889
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-9800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMAD AL-KHUDARI
Title or Position: OWNER
Credential: MD
Phone: 219-836-9800