Provider Demographics
NPI:1457405508
Name:DARYL L CONDON,OD,PC
Entity Type:Organization
Organization Name:DARYL L CONDON,OD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-467-7090
Mailing Address - Street 1:408 W MONDAMIN ST
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-0995
Mailing Address - Country:US
Mailing Address - Phone:815-467-7090
Mailing Address - Fax:815-467-7091
Practice Address - Street 1:408 W MONDAMIN ST
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-0995
Practice Address - Country:US
Practice Address - Phone:815-467-7090
Practice Address - Fax:815-467-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008433152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0581320001Medicare NSC
978880Medicare PIN
ILU32-362Medicare UPIN