Provider Demographics
NPI:1053310482
Name:PIETZ, MARK (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PIETZ
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 1:3000 N HALSTED ST
Mailing Address - Street 2:SUITE 821
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5188
Mailing Address - Country:US
Mailing Address - Phone:773-296-7160
Mailing Address - Fax:773-296-3440
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:SUITE 821
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5188
Practice Address - Country:US
Practice Address - Phone:773-296-7160
Practice Address - Fax:773-296-3440
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-10-28
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-28
Provider Licenses
StateLicense IDTaxonomies
IL016003670213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003670Medicaid
IL1623520OtherBCBS
IL1623520OtherBCBS
ILT37003Medicare UPIN
IL364347776OtherTIN