Provider Demographics
NPI:1992017693
Name:WICKWARE, ELIZABETH KILNER (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:KILNER
Last Name:WICKWARE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:LAURA
Other - Last Name:KILNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:25 E. WASHINGTON STREET
Mailing Address - Street 2:SUITE 606
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602
Mailing Address - Country:US
Mailing Address - Phone:312-444-1111
Mailing Address - Fax:312-444-1953
Practice Address - Street 1:25 E. WASHINGTON STREET
Practice Address - Street 2:SUITE 606
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602
Practice Address - Country:US
Practice Address - Phone:312-444-1111
Practice Address - Fax:312-444-1953
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011209152W00000X
NC2307152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0935BOtherBCBS
NC5922150Medicaid
NCNC8822AMedicare PIN