Provider Demographics
NPI:1477311694
Name:MARK L WESTPHAL
Entity Type:Organization
Organization Name:MARK L WESTPHAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:WESTPHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-549-0841
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-0399
Mailing Address - Country:US
Mailing Address - Phone:618-549-0841
Mailing Address - Fax:618-529-2442
Practice Address - Street 1:665 E LAKE RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5347
Practice Address - Country:US
Practice Address - Phone:618-549-0841
Practice Address - Fax:618-529-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty