Provider Demographics
NPI:1336213495
Name:TRAUBERT, BRYAN S (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:S
Last Name:TRAUBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N SHERIDAN RD
Mailing Address - Street 2:#103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:773-575-8700
Mailing Address - Fax:773-525-8699
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:#103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-575-8700
Practice Address - Fax:773-525-8699
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363843619207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
034270001OtherDME
0001618089OtherBC
IL036066257Medicaid
0001618089OtherBC
IL036066257Medicaid
P11951Medicare ID - Type Unspecified