Provider Demographics
NPI:1790857662
Name:BREI, MARK A (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BREI
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 1:1201 MAINE ST
Mailing Address - Street 2:APT F
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4269
Mailing Address - Country:US
Mailing Address - Phone:217-228-9542
Mailing Address - Fax:
Practice Address - Street 1:3237 QUINCY MALL
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4642
Practice Address - Country:US
Practice Address - Phone:217-224-7132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
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
ILU38795Medicare UPIN
ILL77653Medicare ID - Type Unspecified