Provider Demographics
NPI:1538114616
Name:ARNETT, MARK WELDON (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WELDON
Last Name:ARNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 SOUTH OAK PARK AVE.
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402
Mailing Address - Country:US
Mailing Address - Phone:707-783-3532
Mailing Address - Fax:708-782-3164
Practice Address - Street 1:3 ERIE CT
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2519
Practice Address - Country:US
Practice Address - Phone:707-783-3532
Practice Address - Fax:708-782-3164
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV122592085R0202X
OH25.0000232085R0202X
IL036-0929762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360929761Medicaid
300109946OtherRR MEDICARE
OH4146071Medicare ID - Type Unspecified
ILL72156Medicare ID - Type Unspecified
ILL74278Medicare PIN
300109946OtherRR MEDICARE