Provider Demographics
NPI:1073509766
Name:NEKOLA, MARK ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:NEKOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4900 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-4725
Mailing Address - Country:US
Mailing Address - Phone:618-235-2400
Mailing Address - Fax:618-235-0900
Practice Address - Street 1:3990 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1919
Practice Address - Country:US
Practice Address - Phone:618-277-1130
Practice Address - Fax:618-277-4917
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092365207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08215191OtherBCBS
IL036092365Medicaid
18007717OtherRR MEDICARE
IL08215191OtherBCBS
IL036092365Medicaid