Provider Demographics
NPI:1952509424
Name:ELLISON, MARK ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:ELLISON
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 1:422 W BETHALTO DR
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-1700
Mailing Address - Country:US
Mailing Address - Phone:618-377-5221
Mailing Address - Fax:618-377-5220
Practice Address - Street 1:422 W BETHALTO DR
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010-1700
Practice Address - Country:US
Practice Address - Phone:618-377-5221
Practice Address - Fax:618-377-5220
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007313152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00476034Medicare PIN
ILT37740Medicare UPIN
ILL20274Medicare PIN
IL0241360001Medicare NSC