Provider Demographics
NPI:1043311665
Name:TOMERA, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TOMERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 616
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-0616
Mailing Address - Country:US
Mailing Address - Phone:708-366-7177
Mailing Address - Fax:708-366-3301
Practice Address - Street 1:7579 LAKE ST
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1846
Practice Address - Country:US
Practice Address - Phone:708-366-7177
Practice Address - Fax:708-366-3301
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065652208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065652Medicaid
IL31603127OtherBCBS
ILC45890Medicare UPIN
IL036065652Medicaid