Provider Demographics
NPI:1679507487
Name:LOAFMAN, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:LOAFMAN
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 1:1044 N MOZART ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2789
Mailing Address - Country:US
Mailing Address - Phone:773-292-2600
Mailing Address - Fax:773-292-8266
Practice Address - Street 1:1044 N MOZART
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:773-292-8307
Practice Address - Fax:773-292-8266
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085032Medicaid
IL036085032Medicaid