Provider Demographics
NPI:1225046287
Name:MATRAY, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:MATRAY
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 1:4727 WILLOW SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525
Mailing Address - Country:US
Mailing Address - Phone:708-588-0088
Mailing Address - Fax:708-588-0588
Practice Address - Street 1:4727 WILLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525
Practice Address - Country:US
Practice Address - Phone:708-588-0088
Practice Address - Fax:708-588-0588
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31600935OtherBLUE SHIELD