Provider Demographics
NPI:1861668550
Name:MT. PROSPECT VISION CENTER INC
Entity Type:Organization
Organization Name:MT. PROSPECT VISION CENTER INC
Other - Org Name:EVANSTON EYES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:E
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-475-3937
Mailing Address - Street 1:1962 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1016
Mailing Address - Country:US
Mailing Address - Phone:847-475-3937
Mailing Address - Fax:847-475-9572
Practice Address - Street 1:1962 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1016
Practice Address - Country:US
Practice Address - Phone:847-475-3937
Practice Address - Fax:847-475-9572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007781152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001632664OtherBLUE CROSS /BLUE SHEILD
IL046007781Medicaid