Provider Demographics
NPI:1851440010
Name:OLSWANG, STACY (OD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:OLSWANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 W CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1214
Mailing Address - Country:US
Mailing Address - Phone:773-743-3171
Mailing Address - Fax:
Practice Address - Street 1:3143 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1424
Practice Address - Country:US
Practice Address - Phone:773-764-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009152152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU84494Medicare UPIN
ILL85042Medicare ID - Type Unspecified
ILWANG14Medicare PIN