Provider Demographics
NPI:1790763670
Name:NOBLE, A. GWENDOLYN (MD, PHD)
Entity Type:Individual
Prefix:
First Name:A.
Middle Name:GWENDOLYN
Last Name:NOBLE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:ALMA
Other - Middle Name:GWENDOLYN
Other - Last Name:NOBLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:7638 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-4157
Mailing Address - Country:US
Mailing Address - Phone:708-452-4257
Mailing Address - Fax:708-452-4283
Practice Address - Street 1:7638 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-4157
Practice Address - Country:US
Practice Address - Phone:708-452-4257
Practice Address - Fax:708-452-4283
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-02
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-080087207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363842073Medicaid
IL204200Medicare ID - Type Unspecified
ILF45175Medicare UPIN