Healthcare Provider Details

I. General information

NPI: 1730178971
Provider Name (Legal Business Name): MARK LAWRENCE ZUKOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3612 LAKE AVE
WILMETTE IL
60091-1000
US

IV. Provider business mailing address

2217 MIRAMAR LN
BUFFALO GROVE IL
60089-4692
US

V. Phone/Fax

Practice location:
  • Phone: 847-853-8869
  • Fax: 847-853-8870
Mailing address:
  • Phone: 847-478-8246
  • Fax: 847-478-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: