Provider Demographics
NPI:1154319838
Name:ROLNICK, MARK LEWIS (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEWIS
Last Name:ROLNICK
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 1:3270 CHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-4793
Mailing Address - Country:US
Mailing Address - Phone:314-567-1831
Mailing Address - Fax:
Practice Address - Street 1:3270 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-4793
Practice Address - Country:US
Practice Address - Phone:314-567-1831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003222213E00000X
MO525213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO302590302Medicaid
T55585Medicare UPIN