Provider Demographics
NPI:1790867604
Name:MARK D ESAREY
Entity Type:Organization
Organization Name:MARK D ESAREY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ESAREY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-345-6600
Mailing Address - Street 1:1700 18TH STREET
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920
Mailing Address - Country:US
Mailing Address - Phone:217-345-6600
Mailing Address - Fax:217-345-6622
Practice Address - Street 1:1700 18TH STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920
Practice Address - Country:US
Practice Address - Phone:217-345-6600
Practice Address - Fax:217-345-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1584009OtherBCBS PROV ID#
IL1790867604OtherHEALTH ALLIANCE
IL1790867604OtherPERSONAL CARE
ILDF5536OtherRAILROAD MEDICARE
IL1548267099Medicaid
IL1790867604OtherAFLAC
IL1790867604OtherTRICARE
IL1790867604OtherOSF HEALTHCARE
IL1790867604OtherAFLAC
IL1584009OtherBCBS PROV ID#
IL214236Medicare ID - Type UnspecifiedMEDICARE PROVIDER #