Provider Demographics
NPI:1679769574
Name:DR STANLEY DUSHMAN OD LTD
Entity Type:Organization
Organization Name:DR STANLEY DUSHMAN OD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-800-6691
Mailing Address - Street 1:1671 MISSON HILLS ROAD
Mailing Address - Street 2:#302
Mailing Address - City:NORTH BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5733
Mailing Address - Country:US
Mailing Address - Phone:847-800-6691
Mailing Address - Fax:847-272-1735
Practice Address - Street 1:1671 MISSON HILLS ROAD
Practice Address - Street 2:#302
Practice Address - City:NORTH BROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-5733
Practice Address - Country:US
Practice Address - Phone:847-800-6691
Practice Address - Fax:847-272-1735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2023-03-07
Deactivation Date:2008-08-13
Deactivation Code:
Reactivation Date:2008-11-10
Provider Licenses
StateLicense IDTaxonomies
IL046005878332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046005878Medicaid
IL0184550001OtherDEMERC
IL0184550001OtherDEMERC
ILL08352Medicare PIN
IL0184550001OtherDEMERC