Healthcare Provider Details

I. General information

NPI: 1073509766
Provider Name (Legal Business Name): MARK ALLEN NEKOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 N ILLINOIS ST
SWANSEA IL
62226-1919
US

IV. Provider business mailing address

4900 W MAIN ST
BELLEVILLE IL
62226-4725
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-1130
  • Fax: 618-277-4917
Mailing address:
  • Phone: 618-235-2400
  • Fax: 618-235-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036092365
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: