Provider Demographics
NPI:1437326808
Name:ILYAS OPTICAL INC
Entity Type:Organization
Organization Name:ILYAS OPTICAL INC
Other - Org Name:WILSON OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEWAARD
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:773-271-5774
Mailing Address - Street 1:1217 W WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5516
Mailing Address - Country:US
Mailing Address - Phone:773-271-5774
Mailing Address - Fax:773-271-0741
Practice Address - Street 1:1217 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5516
Practice Address - Country:US
Practice Address - Phone:773-271-5774
Practice Address - Fax:773-271-0741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
IL046007174332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007174Medicaid
IL046007174Medicaid