Provider Demographics
NPI:1457347346
Name:BIGELOW, MARY AGNES (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:AGNES
Last Name:BIGELOW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4174
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-4728
Practice Address - Street 1:106 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1241
Practice Address - Country:US
Practice Address - Phone:217-323-1146
Practice Address - Fax:217-323-1156
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02559152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00390109OtherRAILROAD MEDICARE
ILV11800Medicare UPIN
ILK36207Medicare PIN