Provider Demographics
NPI:1548267099
Name:ESAREY, MARK D (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:ESAREY
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 1:1700 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-3607
Mailing Address - Country:US
Mailing Address - Phone:217-345-6600
Mailing Address - Fax:217-345-6622
Practice Address - Street 1:1700 18TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-3607
Practice Address - Country:US
Practice Address - Phone:217-345-6600
Practice Address - Fax:217-345-6622
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2012-02-24
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
IL046008046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1548267099Medicaid
IL1584009OtherBCBS PROVIDER NUMBER
IL371219488OtherDMERC SUPPLIER NUMBER
IL410024492OtherTRAVELERS MEDICARE
IL371219488OtherDMERC SUPPLIER NUMBER
IL0858860001Medicare NSC
ILT38879Medicare UPIN