Provider Demographics
NPI:1619376571
Name:AVARY, ADA
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:
Last Name:AVARY
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 1:3400 W STONEGATE BLVD APT 316
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1065
Mailing Address - Country:US
Mailing Address - Phone:703-401-2957
Mailing Address - Fax:
Practice Address - Street 1:315 STRATFORD PL STE C-15
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2655
Practice Address - Country:US
Practice Address - Phone:630-295-8031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-16
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010815152WC0802X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics