Provider Demographics
NPI:1124191846
Name:DYGOLA, SHAWN ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:ALAN
Last Name:DYGOLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9707 KEDVALE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1121
Mailing Address - Country:US
Mailing Address - Phone:847-673-6178
Mailing Address - Fax:
Practice Address - Street 1:1947 CHERRY LN
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-3636
Practice Address - Country:US
Practice Address - Phone:847-564-2020
Practice Address - Fax:847-564-2064
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008725152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008725Medicaid
U52909Medicare UPIN
IL046008725Medicaid
ILL33315Medicare ID - Type Unspecified