Provider Demographics
NPI:1154384709
Name:MIHALY, KEITH ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALAN
Last Name:MIHALY
Suffix:
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 1:400 W DUNDEE RD
Mailing Address - Street 2:SUITE 14-15
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3415
Mailing Address - Country:US
Mailing Address - Phone:847-459-9119
Mailing Address - Fax:847-459-8115
Practice Address - Street 1:400 W DUNDEE RD
Practice Address - Street 2:SUITE 14-15
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-3415
Practice Address - Country:US
Practice Address - Phone:847-459-9119
Practice Address - Fax:847-459-8115
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007845152W00000X
FLOPC002198152W00000X
IL18002176A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0410048631OtherMEDICARE ID
IL5303296OtherAETNA
IL1605476OtherBLUE CROSS BLUE SHIELD IL
IL363614738OtherTAX ID
IL363614738OtherCIGNA
IL5303296OtherAETNA
IL363614738OtherCIGNA
IL0403800001Medicare NSC