Provider Demographics
NPI:1952789430
Name:ILTIS, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ILTIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2350 REGENCY RD STE A
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2351
Mailing Address - Country:US
Mailing Address - Phone:859-278-4960
Mailing Address - Fax:859-278-0033
Practice Address - Street 1:2350 REGENCY RD STE A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2351
Practice Address - Country:US
Practice Address - Phone:859-278-4960
Practice Address - Fax:859-278-0033
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2023-06-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY052482086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery