Provider Demographics
NPI:1801914007
Name:FAZELIAN, MARY (OD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FAZELIAN
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 1:5710 LEE ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-3117
Mailing Address - Country:US
Mailing Address - Phone:847-722-8319
Mailing Address - Fax:
Practice Address - Street 1:7305 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-3547
Practice Address - Country:US
Practice Address - Phone:847-722-8319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3190 AT152WX0102X
IL046009825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision