Healthcare Provider Details

I. General information

NPI: 1255369641
Provider Name (Legal Business Name): MARY TJARKS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 JOHN DEERE ROAD, SUITE 200
MOLINE IL
61265-6897
US

IV. Provider business mailing address

600 JOHN DEERE ROAD, SUITE 200
MOLINE IL
61265-6897
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-4230
  • Fax:
Mailing address:
  • Phone: 309-779-4230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5086
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number36102741
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: