Provider Demographics
NPI:1376191445
Name:GONSALVES, ABIGAIL
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4455
Mailing Address - Country:US
Mailing Address - Phone:312-829-6173
Mailing Address - Fax:312-663-4270
Practice Address - Street 1:1613 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-6151
Practice Address - Country:US
Practice Address - Phone:312-363-0202
Practice Address - Fax:312-363-0201
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046.011398OtherILLINOIS OPTOMETRY LICENSE