Provider Demographics
NPI:1760475297
Name:MCMAHON, JANICE M (OD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:M
Other - Last Name:PULA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3849
Mailing Address - Country:US
Mailing Address - Phone:312-949-7323
Mailing Address - Fax:312-949-7642
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3849
Practice Address - Country:US
Practice Address - Phone:312-949-7323
Practice Address - Fax:312-949-7642
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009119Medicaid
U72445Medicare UPIN
IL046009119Medicaid