Provider Demographics
NPI:1447318563
Name:BURGGRAF, RANDALL D
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:D
Last Name:BURGGRAF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 3RD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2762
Mailing Address - Country:US
Mailing Address - Phone:630-232-7800
Mailing Address - Fax:630-232-7819
Practice Address - Street 1:500 S 3RD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2762
Practice Address - Country:US
Practice Address - Phone:630-232-7800
Practice Address - Fax:630-232-7819
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-006713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046006713Medicaid
IL45-3144921OtherEIN
IL4829750001Medicare NSC
IL205201Medicare ID - Type Unspecified
IL046006713Medicaid