Provider Demographics
NPI:1659369353
Name:ILTIS, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:ILTIS
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 1:865 LINCOLN RD
Mailing Address - Street 2:STE L10
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-4190
Mailing Address - Country:US
Mailing Address - Phone:563-355-9191
Mailing Address - Fax:563-355-3419
Practice Address - Street 1:619 5TH STREET
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:IA
Practice Address - Zip Code:52747
Practice Address - Country:US
Practice Address - Phone:563-785-4487
Practice Address - Fax:563-785-6681
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F30147Medicare UPIN