Provider Demographics
NPI:1104946235
Name:SLOTEMAKER, DIANE M (OD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:M
Last Name:SLOTEMAKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:VIRDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1219 S PLYMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2719
Mailing Address - Country:US
Mailing Address - Phone:773-327-3000
Mailing Address - Fax:
Practice Address - Street 1:1730 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1900
Practice Address - Country:US
Practice Address - Phone:773-327-3000
Practice Address - Fax:773-327-3015
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-009028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist