Provider Demographics
NPI:1639334667
Name:GIACOMI, MARK ETTORE JR (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ETTORE
Last Name:GIACOMI
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:23836 W 135TH ST
Mailing Address - Street 2:STE 103
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-5620
Mailing Address - Country:US
Mailing Address - Phone:815-254-2403
Mailing Address - Fax:815-267-8380
Practice Address - Street 1:23836 W 135TH ST
Practice Address - Street 2:STE 103
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-5620
Practice Address - Country:US
Practice Address - Phone:815-254-2403
Practice Address - Fax:815-267-8380
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2021-03-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036126516207Q00000X
IL125054675390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program