Provider Demographics
NPI:1275708265
Name:GONZAGA, MARK ROMELSTEIN CABO (PT)
Entity Type:Individual
Prefix:
First Name:MARK ROMELSTEIN
Middle Name:CABO
Last Name:GONZAGA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1548 E BARONET LN
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-6817
Mailing Address - Country:US
Mailing Address - Phone:847-818-9216
Mailing Address - Fax:847-818-9216
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5823
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:847-998-8008
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist