Provider Demographics
NPI:1770601577
Name:KEOVAN, GOLIE ROSHANDEL (OD)
Entity type:Individual
Prefix:DR
First Name:GOLIE
Middle Name:ROSHANDEL
Last Name:KEOVAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:GOLIE
Other - Middle Name:ROSHANDEL
Other - Last Name:KEOVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3110 W BELMONT AVE
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5788
Mailing Address - Country:US
Mailing Address - Phone:312-626-2376
Mailing Address - Fax:312-626-2398
Practice Address - Street 1:3110 W BELMONT AVE
Practice Address - Street 2:SUITE 1E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5788
Practice Address - Country:US
Practice Address - Phone:312-626-2376
Practice Address - Fax:312-626-2398
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD-991152W00000X
IL046009499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009499Medicaid
IL046009499Medicaid