Provider Demographics
NPI:1972693489
Name:KATZ, BRUCE TERRY (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:TERRY
Last Name:KATZ
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 1:3145 N WILSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-1751
Mailing Address - Country:US
Mailing Address - Phone:847-398-3784
Mailing Address - Fax:
Practice Address - Street 1:3541 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2135
Practice Address - Country:US
Practice Address - Phone:708-425-4162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006345152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T35520Medicare UPIN