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General NPI Number Information
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NPI Number | 1689859811
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Entity Type | Organization
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Legal Business Name | PEDIATRIC OPHTHALMOLOGY, ADULT STRABISMUS CENTER LTD.
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Dates
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Enumeration Date | 01/07/2008
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Last Update Date | 07/18/2008
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Provider Practice Location Address
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Address Line | 1875 W DEMPSTER ST SUITE 610
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City | PARK RIDGE
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State | IL
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Zip | 60068-1186
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Country | US
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Telephone | 847-292-2020
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Fax |
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Provider Business Mailing Address
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Address Line | 1875 W DEMPSTER ST SUITE 610
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City | PARK RIDGE
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State | IL
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Zip | 60068-1186
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Country | US
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Telephone | 847-292-2020
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAVID MITTELMAN
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Credential | M.D.
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Telephone | 847-292-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 3643318
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License Number State | IL
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