Provider Demographics
NPI:1629127881
Name:PANOS, TOM G (OD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:G
Last Name:PANOS
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 1:510 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5104
Mailing Address - Country:US
Mailing Address - Phone:630-858-3937
Mailing Address - Fax:630-858-3948
Practice Address - Street 1:510 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5104
Practice Address - Country:US
Practice Address - Phone:773-585-2022
Practice Address - Fax:773-585-2027
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009606152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU97410Medicare UPIN
ILIL7945001Medicare PIN