Provider Demographics
NPI:1639227499
Name:KAMMER, LEO (OD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:KAMMER
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 1:9859 GILES DR
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-7816
Mailing Address - Country:US
Mailing Address - Phone:708-479-4184
Mailing Address - Fax:
Practice Address - Street 1:320 CHICAGO RIDGE MALL
Practice Address - Street 2:STE #C15
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2602
Practice Address - Country:US
Practice Address - Phone:708-423-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU36364Medicare UPIN
ILL77815Medicare ID - Type Unspecified