Provider Demographics
NPI:1962996181
Name:ETHEZAZ, MARIAM (OD)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:ETHEZAZ
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 1:2501 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2958
Mailing Address - Country:US
Mailing Address - Phone:773-801-3757
Mailing Address - Fax:312-500-5117
Practice Address - Street 1:2305 WILLOW RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7637
Practice Address - Country:US
Practice Address - Phone:847-832-9690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist