Provider Demographics
NPI:1710340724
Name:MAGNUS, MARK KENNETH (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KENNETH
Last Name:MAGNUS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4340
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-0014
Mailing Address - Country:US
Mailing Address - Phone:847-390-7666
Mailing Address - Fax:847-390-9345
Practice Address - Street 1:1455 E GOLF RD STE 110
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1253
Practice Address - Country:US
Practice Address - Phone:847-390-7666
Practice Address - Fax:847-390-9345
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1138213E00000X, 213ES0103X
390200000X
IL016005815213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program