Provider Demographics
NPI:1952785578
Name:KOUTNIK, EDWARD II (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:KOUTNIK
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1548 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5550
Practice Address - Country:US
Practice Address - Phone:773-667-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist