Provider Demographics
NPI:1104806348
Name:PALERMO, MARIO LAWRENCE (OD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:LAWRENCE
Last Name:PALERMO
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 1:18 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1428
Mailing Address - Country:US
Mailing Address - Phone:847-253-8500
Mailing Address - Fax:847-253-8538
Practice Address - Street 1:18 S EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1428
Practice Address - Country:US
Practice Address - Phone:847-253-8500
Practice Address - Fax:847-253-8538
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1684526OtherBLUE CROSS BLUE SHIELD
ILP16016Medicare PIN
IL1684526OtherBLUE CROSS BLUE SHIELD