=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245528140
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKULKUMAR PATEL O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2011
-----------------------------------------------------
Last Update Date | 07/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 S CANAL ST SUITE 108
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-588-0159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9120 HOLLYBERRY AVE
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-4218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-804-5345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046.010452
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------