Provider Demographics
NPI:1366514176
Name:BERKOVICH, EUGENE (OD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:BERKOVICH
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 1:6641 GRAND AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5262
Mailing Address - Country:US
Mailing Address - Phone:847-856-1200
Mailing Address - Fax:847-856-8527
Practice Address - Street 1:6641 GRAND AVE
Practice Address - Street 2:SUITE D
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5262
Practice Address - Country:US
Practice Address - Phone:847-856-1200
Practice Address - Fax:847-856-8527
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46009457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU92373Medicare UPIN