MEDICARE: TRAVIS PARK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	13586	CA
2	152W00000X	Optometrist	046010179	IL

General Provider Information

NPI Number	:	1689830275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS PARK O.D.

Provider Business Mailing Address
First Line	:	1756 W DIVISION ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-7585
Country	:	US
Telephone Number	:	773-489-4848
Fax Number	:	773-489-4848

Provider Business Practice Location Address
First Line	:	1756 W DIVISION ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-7585
Country	:	US
Telephone Number	:	773-489-4848
Fax Number	:	773-489-0808

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2008
Last Update Date	:	04/19/2012

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Directions to “ TRAVIS PARK O.D.” Practice Location

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