Healthcare Provider Details

I. General information

NPI: 1528055969
Provider Name (Legal Business Name): MARK D HAHN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 01/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CHERRY TREE CENTER
WASHINGTON IL
61571-2170
US

IV. Provider business mailing address

8309 N KNOXVILLE AVE
PEORIA IL
61615-2170
US

V. Phone/Fax

Practice location:
  • Phone: 309-444-2277
  • Fax: 309-444-2498
Mailing address:
  • Phone: 309-693-9540
  • Fax: 309-693-9542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number04600009257
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: