Provider Demographics
NPI:1457400525
Name:STEIN, PEGGY DOLORES (OD)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:DOLORES
Last Name:STEIN
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 1:19W146 WOODCREEK PL
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-4553
Mailing Address - Country:US
Mailing Address - Phone:630-427-0819
Mailing Address - Fax:
Practice Address - Street 1:320 CHICAGO RIDGE MALL
Practice Address - Street 2:STE #C15
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2602
Practice Address - Country:US
Practice Address - Phone:708-423-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL77825Medicare ID - Type Unspecified
ILU36136Medicare UPIN