Provider Demographics
NPI:1952437022
Name:DEGROOT, MELISSA
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:DEGROOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N LOUIS ST
Mailing Address - Street 2:UNIT E
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1063 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1854
Practice Address - Country:US
Practice Address - Phone:847-318-7672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist