Provider Demographics
NPI:1992995591
Name:BEHNAM, MARK THOMAS (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:BEHNAM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2553
Mailing Address - Country:US
Mailing Address - Phone:618-392-1131
Mailing Address - Fax:618-395-6084
Practice Address - Street 1:800 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2553
Practice Address - Country:US
Practice Address - Phone:618-392-1131
Practice Address - Fax:618-395-6084
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60184340207V00000X
MDD0092046207V00000X
IL036136070207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0291725OtherSTATE L&I
WA0333366OtherSTATE L&I
IL036136070Medicaid
WA0291725OtherSTATE L&I
IL036136070Medicaid
IL036136070Medicaid
WA0291725OtherSTATE L&I