Provider Demographics
NPI:1790778108
Name:ROBERTS, MARY F (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:F
Other - Last Name:FLYNN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
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:312-949-7309
Mailing Address - Fax:312-949-7653
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:312-225-6200
Practice Address - Fax:319-949-7600
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008468152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008468Medicaid
ILL21902Medicare PIN
IL046008468Medicaid