Provider Demographics
NPI:1396019469
Name:WOLTMAN, BEVERLY (BCO)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:WOLTMAN
Suffix:
Gender:F
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 CAMBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1047
Mailing Address - Country:US
Mailing Address - Phone:630-914-4144
Mailing Address - Fax:
Practice Address - Street 1:6800 S. MAIN STREET
Practice Address - Street 2:SUITE LL5
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516
Practice Address - Country:US
Practice Address - Phone:630-985-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0631512156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist