Provider Demographics
NPI:1427063874
Name:JOHN C ENGSTROM, OD, LTD
Entity type:Organization
Organization Name:JOHN C ENGSTROM, OD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ENGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-255-6075
Mailing Address - Street 1:3487 KIRCHOFF RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-1842
Mailing Address - Country:US
Mailing Address - Phone:847-255-6075
Mailing Address - Fax:847-255-0880
Practice Address - Street 1:3487 KIRCHOFF RD
Practice Address - Street 2:
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-1842
Practice Address - Country:US
Practice Address - Phone:847-255-6075
Practice Address - Fax:847-255-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211486Medicare PIN
IL0620280001Medicare NSC