=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770601577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GOLIE ROSHANDEL KEOVAN O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 09/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3110 W BELMONT AVE SUITE 1E
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-5788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-626-2376
-----------------------------------------------------
Fax | 312-626-2398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3110 W BELMONT AVE SUITE 1E
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-5788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-626-2376
-----------------------------------------------------
Fax | 312-626-2398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD-991
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046009499
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------