Provider Demographics
NPI:1225199623
Name:MONTWILL, EDWARD LEONARD (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEONARD
Last Name:MONTWILL
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 1:11749 SOUTHWEST HWY
Mailing Address - Street 2:STE D
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1053
Mailing Address - Country:US
Mailing Address - Phone:708-361-5236
Mailing Address - Fax:708-361-5489
Practice Address - Street 1:11749 SOUTHWEST HWY
Practice Address - Street 2:SUITE C
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1053
Practice Address - Country:US
Practice Address - Phone:708-361-5236
Practice Address - Fax:708-361-5489
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008324152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU17867Medicare UPIN
IL948820Medicare ID - Type Unspecified