Provider Demographics
NPI:1043388242
Name:WESTPHAL, MARK LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LOUIS
Last Name:WESTPHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-0399
Mailing Address - Country:US
Mailing Address - Phone:618-549-0841
Mailing Address - Fax:618-529-2442
Practice Address - Street 1:665 E LAKE RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5347
Practice Address - Country:US
Practice Address - Phone:618-549-0841
Practice Address - Fax:618-529-2442
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036055065207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0003900142OtherBLUE CROSS BL SH OF IL
IL027382OtherHEALTH ALLIANCE
IL110858OtherHEALTHLINK
IL1073255002OtherCIGNA
C38131Medicare UPIN
IL0003900142OtherBLUE CROSS BL SH OF IL