1659369353 NPI number — MARK P ILTIS MD

Table of content: MARK P ILTIS MD (NPI 1659369353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659369353 NPI number — MARK P ILTIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ILTIS
Provider First Name:
MARK
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659369353
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
865 LINCOLN RD
Provider Second Line Business Mailing Address:
STE L10
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-4190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-355-9191
Provider Business Mailing Address Fax Number:
563-355-3419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
619 5TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-785-4487
Provider Business Practice Location Address Fax Number:
563-785-6681
Provider Enumeration Date:
10/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  27823 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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