Provider Demographics
NPI:1770572620
Name:RIEGER, MARY T (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:T
Last Name:RIEGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ASPEN CT
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1487
Mailing Address - Country:US
Mailing Address - Phone:815-692-2415
Mailing Address - Fax:815-692-2675
Practice Address - Street 1:2 ASPEN CT
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1487
Practice Address - Country:US
Practice Address - Phone:815-692-2415
Practice Address - Fax:815-692-2675
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008997152WC0802X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008997Medicaid
IL05732151OtherBLUE CROSS BLUE SHIELD
ILK49202Medicare PIN
IL05732151OtherBLUE CROSS BLUE SHIELD