Provider Demographics
NPI:1114961208
Name:DZIUBA, ELIZABETH GRACE (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:GRACE
Last Name:DZIUBA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:EIZABETH
Other - Middle Name:GRACE
Other - Last Name:DZIUBA BENTANCUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:373 N WOOD DALE RD
Mailing Address - Street 2:
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-1531
Mailing Address - Country:US
Mailing Address - Phone:630-422-1413
Mailing Address - Fax:630-422-1454
Practice Address - Street 1:373 N WOOD DALE RD
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1531
Practice Address - Country:US
Practice Address - Phone:630-422-1413
Practice Address - Fax:630-422-1454
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008878Medicaid
IL046008878Medicaid