Provider Demographics
NPI:1437186871
Name:DEMBO, BRIAN MARC (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MARC
Last Name:DEMBO
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 1:1545 WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2166
Mailing Address - Country:US
Mailing Address - Phone:847-998-6700
Mailing Address - Fax:847-998-1566
Practice Address - Street 1:1545 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-2166
Practice Address - Country:US
Practice Address - Phone:847-998-6700
Practice Address - Fax:847-998-1566
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01684637OtherBLUE CROSS BLUE SHIELD
021151001OtherADMINISTAR FEDERAL
IL046008000Medicaid
021151001OtherADMINISTAR FEDERAL
780290Medicare ID - Type Unspecified
IL046008000Medicaid