Provider Demographics
NPI:1174670426
Name:GRALAK, KEVIN (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GRALAK
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 1:2733 BUCKINGHAM DR
Mailing Address - Street 2:#309
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-4224
Mailing Address - Country:US
Mailing Address - Phone:630-579-4739
Mailing Address - Fax:815-436-1803
Practice Address - Street 1:3340 MALL LOOP DR
Practice Address - Street 2:1532 36 LOUIS JOLIET MALL
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-1057
Practice Address - Country:US
Practice Address - Phone:815-436-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK01830Medicare ID - Type Unspecified
ILU97407Medicare UPIN