Provider Demographics
NPI:1750320826
Name:HOGAN, JAMIE N (OD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:N
Last Name:HOGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:N
Other - Last Name:LAWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:10320 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4702
Mailing Address - Country:US
Mailing Address - Phone:708-229-2200
Mailing Address - Fax:708-229-2200
Practice Address - Street 1:10320 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4702
Practice Address - Country:US
Practice Address - Phone:708-229-2200
Practice Address - Fax:708-229-2200
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3027152W00000X
FLOPC3899152W00000X
IL046009495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38627100Medicaid
WI38627100Medicaid
000987823Medicare ID - Type Unspecified