MEDICARE: FREDERIC A BANSER OD

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	036095121	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	778910	OTHER	IL	MEDICARE GROUP #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	0001618089	OTHER	BC
3	0342700001	OTHER	DME
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811063431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERIC A BANSER OD

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	866-795-4020

Provider Business Practice Location Address
First Line	:	2842 N SHERIDAN RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-6174
Country	:	US
Telephone Number	:	773-975-4300
Fax Number	:	773-661-1767

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

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	07/25/2019

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Directions to “ FREDERIC A BANSER OD” Practice Location

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