Provider Demographics
NPI:1215659925
Name:MIRZA, SAMREEN (OD)
Entity type:Individual
Prefix:
First Name:SAMREEN
Middle Name:
Last Name:MIRZA
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 1:290 BLUE SPRUCE LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-1762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17W685 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-3545
Practice Address - Country:US
Practice Address - Phone:630-916-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist