Provider Demographics
NPI:1154621316
Name:RANJBAR, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RANJBAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10S372 TIM CT
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6059
Mailing Address - Country:US
Mailing Address - Phone:708-371-9167
Mailing Address - Fax:
Practice Address - Street 1:130 S MANNHEIM RD
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1821
Practice Address - Country:US
Practice Address - Phone:708-547-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010356152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist