Provider Demographics
NPI:1912992470
Name:CAMILLERI, MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:CAMILLERI
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 1:2618 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2725
Mailing Address - Country:US
Mailing Address - Phone:708-788-5232
Mailing Address - Fax:708-788-3618
Practice Address - Street 1:2618 RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2725
Practice Address - Country:US
Practice Address - Phone:708-788-5232
Practice Address - Fax:708-788-3618
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004695213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5734225OtherAETNA
IL60001136OtherBLUE CROSS BLULE SHIELD
IL5734225OtherAETNA
ILU53851Medicare UPIN