Provider Demographics
NPI:1477280733
Name:ANGELES, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ANGELES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1388 BORDEN DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-4367
Mailing Address - Country:US
Mailing Address - Phone:773-470-9050
Mailing Address - Fax:
Practice Address - Street 1:975 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1299
Practice Address - Country:US
Practice Address - Phone:630-443-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008294225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant