Provider Demographics
NPI:1558399949
Name:BURANOSKY, MARK P (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:BURANOSKY
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 1:5600 W ADDISON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4401
Mailing Address - Country:US
Mailing Address - Phone:773-736-1717
Mailing Address - Fax:773-736-7538
Practice Address - Street 1:5600 W ADDISON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4401
Practice Address - Country:US
Practice Address - Phone:773-736-1717
Practice Address - Fax:773-736-7538
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-091198207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-091198Medicaid
ILF72288Medicare UPIN
IL036-091198Medicaid