Provider Demographics
NPI:1578607156
Name:STACK, CATHERINE M (OD)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:M
Last Name:STACK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:876 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137
Mailing Address - Country:US
Mailing Address - Phone:630-469-2418
Mailing Address - Fax:630-469-4680
Practice Address - Street 1:876 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137
Practice Address - Country:US
Practice Address - Phone:630-469-2418
Practice Address - Fax:630-469-4680
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007738152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1083803050OtherGROUP NPI
209576Medicare UPIN