Provider Demographics
NPI:1013954650
Name:WYLES, ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WYLES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:WYLES
Other - Last Name:PEAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4201
Mailing Address - Country:US
Mailing Address - Phone:312-949-9187
Mailing Address - Fax:
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4201
Practice Address - Country:US
Practice Address - Phone:312-949-9187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009904Medicaid
IL046009904Medicaid
ORU95882Medicare UPIN