Provider Demographics
NPI:1104921519
Name:MONDUL, MARK M (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:MONDUL
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 762
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-0762
Mailing Address - Country:US
Mailing Address - Phone:630-232-1013
Mailing Address - Fax:630-232-1014
Practice Address - Street 1:2401 KANEVILLE RD
Practice Address - Street 2:SUITE 6
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2579
Practice Address - Country:US
Practice Address - Phone:630-232-1013
Practice Address - Fax:630-232-1014
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16003529213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60001518OtherBCBS
L016614OtherCHAMPUS
731300Medicare ID - Type Unspecified
IL60001518OtherBCBS
IL0335480001Medicare NSC