MEDICARE: DR. MARK BRIAN COLANDER O.D,

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046010615	IL
2	152W00000X	Optometrist	18003760A	IN

General Provider Information

NPI Number	:	1871889196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BRIAN COLANDER O.D,

Provider Business Mailing Address
First Line	:	11412 S HARLEM AVE
Second Line	:
City	:	WORTH
State	:	IL
Zip	:	60482-2004
Country	:	US
Telephone Number	:	708-422-7000
Fax Number	:	708-448-4295

Provider Business Practice Location Address
First Line	:	11412 S HARLEM AVE
Second Line	:
City	:	WORTH
State	:	IL
Zip	:	60482-2004
Country	:	US
Telephone Number	:	708-422-7000
Fax Number	:	708-448-4295

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2011
Last Update Date	:	09/14/2013

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