Provider Demographics
NPI:1992710578
Name:CABELA, ERWIN (OD)
Entity type:Individual
Prefix:DR
First Name:ERWIN
Middle Name:
Last Name:CABELA
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 1:801 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3118
Mailing Address - Country:US
Mailing Address - Phone:708-369-7346
Mailing Address - Fax:708-493-0144
Practice Address - Street 1:4113 SAINT CHARLES RD
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-1145
Practice Address - Country:US
Practice Address - Phone:708-493-9306
Practice Address - Fax:708-493-0144
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001636017OtherBCBS OF ILLINOIS
ILU74060Medicare UPIN
ILK20990Medicare ID - Type Unspecified