Provider Demographics
NPI:1659423655
Name:ROSS, MARK I (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:I
Last Name:ROSS
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:490 COVENTRY LN STE 201
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7548
Mailing Address - Country:US
Mailing Address - Phone:815-455-5034
Mailing Address - Fax:815-455-5041
Practice Address - Street 1:490 COVENTRY LN STE 201
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7548
Practice Address - Country:US
Practice Address - Phone:815-455-5034
Practice Address - Fax:815-455-5041
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL46008014152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1148002Medicare PIN