Provider Demographics
NPI:1295791622
Name:LONDOS, GLENN R (OD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:LONDOS
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 1:1234 LATHROP AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1116
Mailing Address - Country:US
Mailing Address - Phone:708-771-5537
Mailing Address - Fax:
Practice Address - Street 1:1103 E 31ST ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1280
Practice Address - Country:US
Practice Address - Phone:708-588-1781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007566152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1684555OtherBLUE CROSS BLUE SHIELD
IL046007566Medicaid
IL195546334402OtherHUMANA
ILT-38120Medicare UPIN
IL195546334402OtherHUMANA