Provider Demographics
NPI:1689722290
Name:MACKERT, DAMON W (OD)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:W
Last Name:MACKERT
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 1:1402 BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1031
Mailing Address - Country:US
Mailing Address - Phone:630-629-2025
Mailing Address - Fax:
Practice Address - Street 1:1402 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1031
Practice Address - Country:US
Practice Address - Phone:630-629-2025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK17526Medicare ID - Type Unspecified
ILU56581Medicare UPIN