Healthcare Provider Details

I. General information

NPI: 1457304156
Provider Name (Legal Business Name): MARK A WARGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E ELM ST
STREATOR IL
61364-2223
US

IV. Provider business mailing address

109 E ELM ST
STREATOR IL
61364-2223
US

V. Phone/Fax

Practice location:
  • Phone: 815-672-4587
  • Fax: 815-673-3582
Mailing address:
  • Phone: 815-672-4587
  • Fax: 815-673-3582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036099987
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: