Provider Demographics
NPI:1255389805
Name:SEDORY, MARK JOHN (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:SEDORY
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 2382
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-8482
Mailing Address - Country:US
Mailing Address - Phone:708-352-5121
Mailing Address - Fax:708-352-5121
Practice Address - Street 1:132 N CATHERINE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-1828
Practice Address - Country:US
Practice Address - Phone:708-352-5121
Practice Address - Fax:708-352-5121
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003538213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL426740Medicare ID - Type Unspecified
ILT38590Medicare UPIN