Provider Demographics
NPI:1003994112
Name:SPACCAPANICCIA, MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SPACCAPANICCIA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 S HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5371
Mailing Address - Country:US
Mailing Address - Phone:630-495-3338
Mailing Address - Fax:630-495-3350
Practice Address - Street 1:2340 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5371
Practice Address - Country:US
Practice Address - Phone:630-495-3338
Practice Address - Fax:630-495-3350
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060015180OtherBCBS
IL0060015182OtherBCBS
IL4392600001Medicare NSC
ILL83525Medicare PIN
IL0060015182OtherBCBS