Provider Demographics
NPI:1336998293
Name:BEDELL, MARA TERESA
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:TERESA
Last Name:BEDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 N JANSSEN AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1322
Mailing Address - Country:US
Mailing Address - Phone:440-665-7010
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 906
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3848
Practice Address - Country:US
Practice Address - Phone:312-733-7566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL046011870152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program