Provider Demographics
NPI:1114026754
Name:MONTEFOLKA, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MONTEFOLKA
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 1:1120 E WAR MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616
Mailing Address - Country:US
Mailing Address - Phone:309-685-0100
Mailing Address - Fax:309-685-0172
Practice Address - Street 1:1120 E WAR MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616
Practice Address - Country:US
Practice Address - Phone:309-685-0100
Practice Address - Fax:309-685-0172
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK09678OtherPIN
ILK09678OtherPIN
ILI16105Medicare UPIN