Provider Demographics
NPI:1407631708
Name:MOUKADDEM, MUNIRA
Entity Type:Individual
Prefix:
First Name:MUNIRA
Middle Name:
Last Name:MOUKADDEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9236 S THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-2162
Mailing Address - Country:US
Mailing Address - Phone:708-566-7960
Mailing Address - Fax:
Practice Address - Street 1:9531 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3136
Practice Address - Country:US
Practice Address - Phone:708-423-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011787152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist