Provider Demographics
NPI:1679647291
Name:GRAVES, MARK V (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:V
Last Name:GRAVES
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 1:2727 S ELEANOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-5402
Mailing Address - Country:US
Mailing Address - Phone:773-843-2208
Mailing Address - Fax:
Practice Address - Street 1:6233 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2317
Practice Address - Country:US
Practice Address - Phone:708-749-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL046-009082152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U72358Medicare UPIN
L68515Medicare PIN
L66275Medicare PIN