Provider Demographics
NPI:1144212028
Name:PRENTICE, LEO J (OD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:J
Last Name:PRENTICE
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 1:7451 WOODWARD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2665
Mailing Address - Country:US
Mailing Address - Phone:630-663-9112
Mailing Address - Fax:630-663-9228
Practice Address - Street 1:7451 WOODWARD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2665
Practice Address - Country:US
Practice Address - Phone:630-663-9112
Practice Address - Fax:630-663-9228
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL634330Medicare ID - Type Unspecified
ILT37348Medicare UPIN