Provider Demographics
NPI:1255479358
Name:ZAJICEK, RICHARD MARK (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARK
Last Name:ZAJICEK
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 1:720 WELLINGTON AVE
Mailing Address - Street 2:UNIT 415
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3366
Mailing Address - Country:US
Mailing Address - Phone:847-340-0877
Mailing Address - Fax:
Practice Address - Street 1:3141 S VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6565
Practice Address - Country:US
Practice Address - Phone:217-793-2273
Practice Address - Fax:217-793-2278
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL047933072OtherIL ANCILLARY LIC ALGONQUI
IL046007387OtherSTATE GENERAL LICENSE
IL1684405OtherBCBS PROVIDER NUMBER
IL346000315OtherSTATE THERAPEUTIC LICENSE
IL346002621OtherIL ANC THERAP ALGONQUIN
IL346002621OtherIL ANC THERAP ALGONQUIN
IL1684405OtherBCBS PROVIDER NUMBER