Provider Demographics
NPI:1245423300
Name:WELTZER-MAITE,P.C.
Entity Type:Organization
Organization Name:WELTZER-MAITE,P.C.
Other - Org Name:PEARLE VISION EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:P
Authorized Official - Last Name:VIDULICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-327-3000
Mailing Address - Street 1:400 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1727
Mailing Address - Country:US
Mailing Address - Phone:312-274-1212
Mailing Address - Fax:
Practice Address - Street 1:400 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1727
Practice Address - Country:US
Practice Address - Phone:312-274-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6054620001Medicare NSC