MEDICARE: MARY FAZELIAN 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	152WX0102X	Occupational Vision Optometrist	3190 AT	OR
2	152W00000X	Optometrist	046009825	IL

General Provider Information

NPI Number	:	1801914007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY FAZELIAN O.D.

Provider Business Mailing Address
First Line	:	5710 LEE ST
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-3117
Country	:	US
Telephone Number	:	847-722-8319
Fax Number	:

Provider Business Practice Location Address
First Line	:	7305 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-3547
Country	:	US
Telephone Number	:	847-722-8319
Fax Number	:

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	05/22/2012

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