Provider Demographics
NPI:1043306889
Name:BLOUNT-ODUM, LAURA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:MARIE
Last Name:BLOUNT-ODUM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507 W WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-4125
Mailing Address - Country:US
Mailing Address - Phone:773-725-7283
Mailing Address - Fax:
Practice Address - Street 1:4949 W. IRVING PARK RD.
Practice Address - Street 2:SUITE E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2641
Practice Address - Country:US
Practice Address - Phone:773-237-4774
Practice Address - Fax:773-202-9902
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist