Provider Demographics
NPI:1174582191
Name:FRANK, KRISTY MARCZEWSKI (OD)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:MARCZEWSKI
Last Name:FRANK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:ANN
Other - Last Name:MARCZEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2570 DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3109
Mailing Address - Country:US
Mailing Address - Phone:815-758-1039
Mailing Address - Fax:
Practice Address - Street 1:2570 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3109
Practice Address - Country:US
Practice Address - Phone:815-758-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009660Medicaid
IL046009660Medicaid
IL213113Medicare ID - Type UnspecifiedGROUP NUMBER