Provider Demographics
NPI:1760744825
Name:MOTHERSBAUGH, ERIK J (OD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:J
Last Name:MOTHERSBAUGH
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 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3878
Mailing Address - Country:US
Mailing Address - Phone:312-225-6200
Mailing Address - Fax:312-949-7389
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3878
Practice Address - Country:US
Practice Address - Phone:312-225-6200
Practice Address - Fax:312-949-7389
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010542Medicaid
IL502720058OtherMEDICARE PTAN