=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043575566
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRANT WILLIAM GOBLE O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2012
-----------------------------------------------------
Last Update Date | 12/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2475 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-829-2020
-----------------------------------------------------
Fax | 773-770-3497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2475 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-829-2020
-----------------------------------------------------
Fax | 773-770-3497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046010585
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------