Provider Demographics
NPI:1073686416
Name:SBLENDORIO, MARK S (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:SBLENDORIO
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 1:14262 SELVA LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1788
Mailing Address - Country:US
Mailing Address - Phone:708-873-0943
Mailing Address - Fax:
Practice Address - Street 1:9900 RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1241
Practice Address - Country:US
Practice Address - Phone:708-422-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL337960Medicare ID - Type Unspecified
ILU47267Medicare UPIN