1679769574 NPI number — DR STANLEY DUSHMAN OD LTD

Table of content: (NPI 1679769574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679769574 NPI number — DR STANLEY DUSHMAN OD LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR STANLEY DUSHMAN OD LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679769574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/13/2008
NPI Reactivation Date:
11/10/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1671 MISSON HILLS ROAD
Provider Second Line Business Mailing Address:
#302
Provider Business Mailing Address City Name:
NORTH BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-5733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-800-6691
Provider Business Mailing Address Fax Number:
847-272-1735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1671 MISSON HILLS ROAD
Provider Second Line Business Practice Location Address:
#302
Provider Business Practice Location Address City Name:
NORTH BROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60062-5733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-800-6691
Provider Business Practice Location Address Fax Number:
847-272-1735
Provider Enumeration Date:
09/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUSHMAN
Authorized Official First Name:
STANLEY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
847-800-6691

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  046005878 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 046005878 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0184550001 . This is a "DEMERC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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