Provider Demographics
NPI:1124339387
Name:ILYAS OPTICAL INC.
Entity type:Organization
Organization Name:ILYAS OPTICAL INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEWAARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-345-4040
Mailing Address - Street 1:217 S 5TH AVE # B
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-1647
Mailing Address - Country:US
Mailing Address - Phone:708-345-4040
Mailing Address - Fax:708-345-5534
Practice Address - Street 1:217 S 5TH AVE # B
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-1647
Practice Address - Country:US
Practice Address - Phone:708-345-4040
Practice Address - Fax:708-345-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty