Provider Demographics
NPI:1497735708
Name:FELDMAN, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:FELDMAN
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 1:311 W LINCOLN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1902
Mailing Address - Country:US
Mailing Address - Phone:618-233-3661
Mailing Address - Fax:618-233-0992
Practice Address - Street 1:311 W LINCOLN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1902
Practice Address - Country:US
Practice Address - Phone:618-233-3661
Practice Address - Fax:618-233-0992
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058043174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371123307OtherTAX ID #
IL036058043Medicaid
IL371123307OtherTAX ID #