Provider Demographics
NPI:1295898211
Name:WIECZOREK, STEPHANIE A (OD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:WIECZOREK
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 1:1719 W DIVERSEY PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1009
Mailing Address - Country:US
Mailing Address - Phone:312-498-9363
Mailing Address - Fax:
Practice Address - Street 1:7601 S CICERO AVE
Practice Address - Street 2:FORD CITY MALL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-1022
Practice Address - Country:US
Practice Address - Phone:773-582-8030
Practice Address - Fax:773-582-9396
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009385152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL579250019Medicare PIN
IL162619Medicare UPIN