Provider Demographics
NPI:1386493187
Name:STALEVA, PETKANA K
Entity type:Individual
Prefix:
First Name:PETKANA
Middle Name:K
Last Name:STALEVA
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 1:3241 S MICHIGAN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3878
Mailing Address - Country:US
Mailing Address - Phone:312-225-6200
Mailing Address - Fax:312-949-7616
Practice Address - Street 1:3241 S MICHIGAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3878
Practice Address - Country:US
Practice Address - Phone:312-225-6200
Practice Address - Fax:312-949-7616
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011884152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program