Provider Demographics
NPI:1003896978
Name:KONIECZNY, MARK A (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:KONIECZNY
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:1220 HOBSON RD
Mailing Address - Street 2:STE 248
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-8138
Mailing Address - Country:US
Mailing Address - Phone:630-355-9811
Mailing Address - Fax:630-548-3905
Practice Address - Street 1:1220 HOBSON RD
Practice Address - Street 2:STE 248
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-8138
Practice Address - Country:US
Practice Address - Phone:630-355-9811
Practice Address - Fax:630-548-3905
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2016-11-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL016003378213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL691230Medicare ID - Type Unspecified
ILT37895Medicare UPIN