Provider Demographics
NPI:1649344482
Name:NEIBERG, MARYKE NIJHUIS (OD)
Entity type:Individual
Prefix:DR
First Name:MARYKE
Middle Name:NIJHUIS
Last Name:NEIBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3450 LACEY RD
Mailing Address - Street 2:SUITE 272
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5430
Mailing Address - Country:US
Mailing Address - Phone:630-743-4967
Mailing Address - Fax:630-743-4537
Practice Address - Street 1:3450 LACEY RD
Practice Address - Street 2:SUITE 272
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5430
Practice Address - Country:US
Practice Address - Phone:630-743-4967
Practice Address - Fax:630-743-4537
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010954152W00000X
FLOFC21152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010954Medicaid
FLV01698Medicare UPIN
ILF400271061Medicare PIN