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General NPI Number Information
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NPI Number | 1467940254
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Entity Type | Organization
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Legal Business Name | OPHTHALMOLOGY CONSULTANTS OF ILLINOIS, S.C.
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Dates
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Enumeration Date | 04/26/2018
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Last Update Date | 04/26/2018
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Provider Practice Location Address
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Address Line | 7001 W ARCHER AVE
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City | CHICAGO
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State | IL
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Zip | 60638-2201
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Country | US
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Telephone | 773-229-8818
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Fax | 773-229-8423
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Provider Business Mailing Address
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Address Line | 409 W OGDEN AVE
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City | WESTMONT
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State | IL
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Zip | 60559-1421
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Country | US
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Telephone | 309-649-8006
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Fax | 888-598-6004
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Authorized Official
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Title or Position | OWNER
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Name | BABU NARAYAN PONAKALA
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Credential | MD
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Telephone | 630-964-9800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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