Provider Demographics
NPI:1801902432
Name:KLUCKA, MARK T (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:KLUCKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 959203
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-1281
Mailing Address - Country:US
Mailing Address - Phone:618-463-7874
Mailing Address - Fax:618-463-7846
Practice Address - Street 1:4 MEMORIAL DR STE 230
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6704
Practice Address - Country:US
Practice Address - Phone:618-463-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.077227207RG0100X
IL036077227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077227Medicaid
IL100013015OtherRAILROAD MEDICARE
IL100013015OtherRAILROAD MEDICARE