Provider Demographics
NPI:1255532248
Name:IDOC INC.
Entity type:Organization
Organization Name:IDOC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY- PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERWIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:CABELA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-369-7346
Mailing Address - Street 1:4113 SAINT CHARLES RD
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-1145
Mailing Address - Country:US
Mailing Address - Phone:708-493-9306
Mailing Address - Fax:708-493-0144
Practice Address - Street 1:4113 SAINT CHARLES RD
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-1145
Practice Address - Country:US
Practice Address - Phone:708-493-9306
Practice Address - Fax:708-493-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212303Medicare PIN
ILK20990Medicare UPIN
ILU74060Medicare UPIN