Provider Demographics
NPI:1285622639
Name:RALICK, VERONICA (OD)
Entity type:Individual
Prefix:DR
First Name:VERONICA
Middle Name:
Last Name:RALICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:VERONICA
Other - Middle Name:
Other - Last Name:MOLINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2212 SOUTHLAKE MALL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6441
Mailing Address - Country:US
Mailing Address - Phone:219-736-0093
Mailing Address - Fax:219-736-0396
Practice Address - Street 1:2212 SOUTHLAKE MALL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6441
Practice Address - Country:US
Practice Address - Phone:219-736-0093
Practice Address - Fax:219-736-0396
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1459152W00000X
IN18003290A,B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105245Medicare ID - Type UnspecifiedMEDICARE/MEDICAID NUMBER
AZV06436Medicare UPIN
AZ105244Medicare ID - Type UnspecifiedMEDICARE/MEDICAID NUMBER