Provider Demographics
NPI:1043261282
Name:GAGNON, MARK JAMES (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:GAGNON
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:7355 ARCHER AVE
Mailing Address - Street 2:UNIT D
Mailing Address - City:SUMMIT
Mailing Address - State:IL
Mailing Address - Zip Code:60501-1225
Mailing Address - Country:US
Mailing Address - Phone:773-229-8200
Mailing Address - Fax:773-229-9752
Practice Address - Street 1:7355 ARCHER AVE
Practice Address - Street 2:UNIT D
Practice Address - City:SUMMIT
Practice Address - State:IL
Practice Address - Zip Code:60501-1225
Practice Address - Country:US
Practice Address - Phone:773-229-8200
Practice Address - Fax:773-229-9752
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2021-12-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL016004840213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U69415Medicare UPIN