Provider Demographics
NPI:1982991980
Name:BURGOS, MARY G (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:G
Last Name:BURGOS
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 1:400 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1511
Mailing Address - Country:US
Mailing Address - Phone:630-940-6629
Mailing Address - Fax:888-388-2329
Practice Address - Street 1:400 W LAKE ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-1511
Practice Address - Country:US
Practice Address - Phone:630-940-6629
Practice Address - Fax:888-388-2329
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010443152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8210Medicare PIN