Provider Demographics
NPI:1265525729
Name:OTTOLIN, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:OTTOLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:100 SPALDING DRIVE
Practice Address - Street 2:SUITE 212
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60504-6552
Practice Address - Country:US
Practice Address - Phone:630-357-4111
Practice Address - Fax:630-357-4644
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-064112207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44217Medicare UPIN
ILP12144Medicare UPIN
IL036-064112Medicaid