MEDICARE: MARK TAKESUYE, OD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	152W00000X	Optometrist
2	152WC0802X	Corneal and Contact Management Optometrist
3	152WP0200X	Pediatric Optometrist
4	152WV0400X	Vision Therapy Optometrist

General Provider Information

NPI Number	:	1811457179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK TAKESUYE, OD, LLC

Provider Business Mailing Address
First Line	:	3232 W BRYN MAWR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3606
Country	:	US
Telephone Number	:	773-588-4433
Fax Number	:

Provider Business Practice Location Address
First Line	:	3232 W BRYN MAWR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3606
Country	:	US
Telephone Number	:	773-588-4433
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. MARK TAKESUYE
Credential	:	OD
Telephone Number	:	773-588-4433

Provider Enumeration Date	:	03/22/2019
Last Update Date	:	03/22/2019

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