Provider Demographics
NPI:1578619391
Name:BLANK, ROGER (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:BLANK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 CORTLAND DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2366
Mailing Address - Country:US
Mailing Address - Phone:847-975-1653
Mailing Address - Fax:
Practice Address - Street 1:603 CORTLAND DR
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2366
Practice Address - Country:US
Practice Address - Phone:847-975-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU05239Medicare UPIN