Provider Demographics
NPI:1942285572
Name:GOSPODINOFF, MARIO L (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:L
Last Name:GOSPODINOFF
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 1:1301 ENTERPRISE WAY
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4442
Mailing Address - Country:US
Mailing Address - Phone:618-993-1122
Mailing Address - Fax:
Practice Address - Street 1:1301 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4442
Practice Address - Country:US
Practice Address - Phone:618-993-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360402792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036040279Medicaid
IL370966854011Medicaid
ILK05556Medicare ID - Type Unspecified
IL370966854011Medicaid
ILE36986Medicare UPIN