Provider Demographics
NPI:1992854269
Name:MOURELATOS, ANTONIA (OD)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:MOURELATOS
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 1:918 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-7232
Mailing Address - Country:US
Mailing Address - Phone:630-629-2026
Mailing Address - Fax:630-629-7640
Practice Address - Street 1:950 W. RT. 22
Practice Address - Street 2:LOSSMAN EYE CARE
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-1031
Practice Address - Country:US
Practice Address - Phone:847-726-2020
Practice Address - Fax:630-629-7640
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009382152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU87477Medicare UPIN
ILL88813Medicare ID - Type Unspecified