Healthcare Provider Details

I. General information

NPI: 1720461940
Provider Name (Legal Business Name): HOLLY OBOIKOVITZ O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

179 N CHICAGO ST APT 313
JOLIET IL
60432-4126
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 815-723-2020
  • Fax: 815-724-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.010902
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: