Provider Demographics
NPI:1801100094
Name:OTTAVIANO, ADAM J
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:J
Last Name:OTTAVIANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 ELISHA AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2607
Mailing Address - Country:US
Mailing Address - Phone:847-746-1223
Mailing Address - Fax:847-746-1225
Practice Address - Street 1:2625 ELISHA AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2607
Practice Address - Country:US
Practice Address - Phone:847-746-1223
Practice Address - Fax:847-746-1225
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL346.003090046.010342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216799001OtherMEDICARE PTAN