Provider Demographics
NPI:1972649432
Name:WALSER, JANICE MARY (OD)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:MARY
Last Name:WALSER
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 1:1121 WARREN AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3570
Mailing Address - Country:US
Mailing Address - Phone:630-969-0402
Mailing Address - Fax:630-969-1674
Practice Address - Street 1:1121 WARREN AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-3570
Practice Address - Country:US
Practice Address - Phone:630-969-0402
Practice Address - Fax:630-969-1674
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38184Medicare UPIN
IL724320Medicare ID - Type UnspecifiedOPTOMETRIST
IL0240680001Medicare NSC