Healthcare Provider Details

I. General information

NPI: 1639334667
Provider Name (Legal Business Name): MARK ETTORE GIACOMI JR. D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23836 W 135TH ST STE 103
PLAINFIELD IL
60544-5620
US

IV. Provider business mailing address

23836 W 135TH ST STE 103
PLAINFIELD IL
60544-5620
US

V. Phone/Fax

Practice location:
  • Phone: 815-254-2403
  • Fax: 815-267-8380
Mailing address:
  • Phone: 815-254-2403
  • Fax: 815-267-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036126516
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: