Provider Demographics
NPI:1841385267
Name:SPENCER, MARK DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:SPENCER
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 1:4949 W.IRVING PK. RD.
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2655
Mailing Address - Country:US
Mailing Address - Phone:773-237-4774
Mailing Address - Fax:773-202-9902
Practice Address - Street 1:4949 W.IRVING PK. RD.
Practice Address - Street 2:SUITE E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2655
Practice Address - Country:US
Practice Address - Phone:773-237-4774
Practice Address - Fax:773-202-9902
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-0008177152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001607656OtherBCBS
IL911631Medicare ID - Type Unspecified
IL0001607656OtherBCBS