Organization
MARK D ESAREY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARK D ESAREY OD (OWNER)
(217) 345-6600
Entity
Organization
Contact information
Practice address
1700 18TH STREET, CHARLESTON, IL 61920
(217) 345-6600
(217) 345-6622
Mailing address
1700 18TH STREET, CHARLESTON, IL 61920
(217) 345-6600
(217) 345-6622
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1548267099
—
IL
01
—
1584009
BCBS PROV ID#
IL
01
—
1790867604
HEALTH ALLIANCE
IL
01
—
DF5536
RAILROAD MEDICARE
IL
Enumeration date
10/19/2006
Last updated
03/05/2012
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