Provider Demographics
NPI:1497741342
Name:FRIED, WALTER I (PHD, MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:I
Last Name:FRIED
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3477 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3734
Mailing Address - Country:US
Mailing Address - Phone:847-249-4660
Mailing Address - Fax:847-249-4950
Practice Address - Street 1:3477 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3734
Practice Address - Country:US
Practice Address - Phone:847-249-4660
Practice Address - Fax:847-249-4950
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050042207W00000X
WI29201020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050042Medicaid
ILD10232Medicare UPIN
ILL33457Medicare PIN