Provider Demographics
NPI:1811457179
Name:MARK TAKESUYE, OD, LLC
Entity type:Organization
Organization Name:MARK TAKESUYE, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKESUYE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-588-4433
Mailing Address - Street 1:3232 W BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3606
Mailing Address - Country:US
Mailing Address - Phone:773-588-4433
Mailing Address - Fax:
Practice Address - Street 1:3232 W BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3606
Practice Address - Country:US
Practice Address - Phone:773-588-4433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty