Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | IL | |
Y | 222Z00000X | Podiatrist | IL |
NPI | 1003994112 |
---|---|
Provider Name | Dr. Mark Spaccapaniccia |
First Address | Lombard, IL 60148-5371 |
Second Address | Lombard, IL 60148-5371 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2006 |
Last Update Date | 09/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0060015180 | BCBS (01) | IL |
0060015182 | BCBS (01) | IL |
T38180 | (02) | IL |