Provider Demographics
NPI:1306848387
Name:GLESENER, MARK JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:GLESENER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1750 E MAIN ST
Mailing Address - Street 2:SUITE #60
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2363
Mailing Address - Country:US
Mailing Address - Phone:630-377-8844
Mailing Address - Fax:630-377-8404
Practice Address - Street 1:1750 E MAIN ST
Practice Address - Street 2:SUITE #60
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2363
Practice Address - Country:US
Practice Address - Phone:630-377-8844
Practice Address - Fax:630-377-8404
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006085111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532055OtherBLUE CROSS BLUE SHIELD #
ILT39014Medicare UPIN
ILK13653Medicare ID - Type UnspecifiedMEDICARE NUMBER