Provider Demographics
NPI:1336021187
Name:PETKO, ALYSSA MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:MICHELLE
Last Name:PETKO
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 1:5 N WABASH AVE APT 1505
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-4743
Mailing Address - Country:US
Mailing Address - Phone:847-275-1291
Mailing Address - Fax:
Practice Address - Street 1:111 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-4628
Practice Address - Country:US
Practice Address - Phone:312-265-0444
Practice Address - Fax:312-929-4213
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.012008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist