Provider Demographics
NPI:1316026313
Name:HEIMLICH, MARVIN HAROLD (OD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:HAROLD
Last Name:HEIMLICH
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 1:713 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1747
Mailing Address - Country:US
Mailing Address - Phone:847-256-2645
Mailing Address - Fax:847-541-1184
Practice Address - Street 1:307 S MILWAUKEE AVE
Practice Address - Street 2:LIBERTYVILLE VISION CENTER
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-541-1184
Practice Address - Fax:847-541-1194
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
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
ILL26490Medicare ID - Type UnspecifiedMEDICARE GRP PROVIDER NUM
ILL17715Medicare ID - Type UnspecifiedMEDICARE GRP PROVIDER NUM
IL764810Medicare ID - Type UnspecifiedMEDICARE INDIV NUMBER
ILT38742Medicare UPIN