Provider Demographics
NPI:1851680839
Name:JUNGIEWICZ, MARCIN (DO)
Entity type:Individual
Prefix:DR
First Name:MARCIN
Middle Name:
Last Name:JUNGIEWICZ
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 GATEWAY DR STE 103
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3192
Mailing Address - Country:US
Mailing Address - Phone:815-758-8671
Mailing Address - Fax:815-756-4892
Practice Address - Street 1:1850 GATEWAY DR STE 103
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-758-8671
Practice Address - Fax:815-756-4892
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.015434207QS0010X
IL125059120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036137479OtherSTATE LICENSE
OH0464588Medicaid