Provider Demographics
NPI:1336205368
Name:LEDERER, PAUL JOSEPH (OD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:JOSEPH
Last Name:LEDERER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3250 N ARLINGTON HEIGHTS RD STE 109
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-1574
Mailing Address - Country:US
Mailing Address - Phone:847-255-1040
Mailing Address - Fax:847-506-0843
Practice Address - Street 1:3250 N. ARLINGTON HEIGHTS RD.
Practice Address - Street 2:SUITE 109
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1534
Practice Address - Country:US
Practice Address - Phone:847-255-1040
Practice Address - Fax:847-506-0843
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46006351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1684003OtherBLIE CORSS BLUE SHIELD
T36679Medicare UPIN