Provider Demographics
NPI:1639234404
Name:PAUNICKA, MARK D (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:PAUNICKA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2746
Mailing Address - Country:US
Mailing Address - Phone:217-367-3333
Mailing Address - Fax:217-367-3190
Practice Address - Street 1:405 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2746
Practice Address - Country:US
Practice Address - Phone:217-367-3333
Practice Address - Fax:217-367-3190
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038003818Medicaid
IL683970Medicare ID - Type Unspecified