Provider Demographics
NPI:1578857264
Name:ZAJACKOWSKI, MARK EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EUGENE
Last Name:ZAJACKOWSKI
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 1:5445 N SHERIDAN RD
Mailing Address - Street 2:#3102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1957
Mailing Address - Country:US
Mailing Address - Phone:773-271-0609
Mailing Address - Fax:
Practice Address - Street 1:5445 N SHERIDAN RD
Practice Address - Street 2:#3102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1957
Practice Address - Country:US
Practice Address - Phone:773-271-0609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-051907208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice