Provider Demographics
NPI:1184655441
Name:VIDULICH, SPENCER PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:PAUL
Last Name:VIDULICH
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 1:1730 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1900
Mailing Address - Country:US
Mailing Address - Phone:773-327-3000
Mailing Address - Fax:773-327-3015
Practice Address - Street 1:1730 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1900
Practice Address - Country:US
Practice Address - Phone:773-327-3000
Practice Address - Fax:773-327-3015
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL18482Medicare UPIN
ILL25321Medicare UPIN