Provider Demographics
NPI:1881796589
Name:MAZE, DAVID A (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:MAZE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:SHARON
Other - Middle Name:M
Other - Last Name:LUCKHARDT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:136 N CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-1604
Mailing Address - Country:US
Mailing Address - Phone:630-969-2807
Mailing Address - Fax:630-969-2894
Practice Address - Street 1:136 N CASS AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1604
Practice Address - Country:US
Practice Address - Phone:630-969-2807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009686152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5984120001OtherPTAN
ILK16173OtherK NUMBER