Provider Demographics
NPI:1801663943
Name:HADDAD, LAUREN ANSEMOSS (OD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ANSEMOSS
Last Name:HADDAD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 SHADOW RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1979
Mailing Address - Country:US
Mailing Address - Phone:708-833-3420
Mailing Address - Fax:
Practice Address - Street 1:210 SHADOW RIDGE CT
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1979
Practice Address - Country:US
Practice Address - Phone:708-833-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011817152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist