Provider Demographics
NPI:1104833631
Name:DOLZ, MARK STEPHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHAN
Last Name:DOLZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 RELIABLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686
Mailing Address - Country:US
Mailing Address - Phone:217-788-3000
Mailing Address - Fax:217-788-5577
Practice Address - Street 1:1600 W WALNUT
Practice Address - Street 2:PASSAVANT AREA HOSPITAL - LABORATORY
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-245-9541
Practice Address - Fax:217-479-5648
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360944131Medicaid
IL0360944131Medicaid
I19488Medicare UPIN