Healthcare Provider Details

I. General information

NPI: 1952509424
Provider Name (Legal Business Name): MARK ALLEN ELLISON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 W BETHALTO DR
BETHALTO IL
62010-1700
US

IV. Provider business mailing address

422 W BETHALTO DR
BETHALTO IL
62010-1700
US

V. Phone/Fax

Practice location:
  • Phone: 618-377-5221
  • Fax: 618-377-5220
Mailing address:
  • Phone: 618-377-5221
  • Fax: 618-377-5220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-007313
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: