Provider Demographics
NPI:1043341068
Name:FENLON, MARK ANDREW (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:FENLON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12620 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1428
Mailing Address - Country:US
Mailing Address - Phone:708-361-3338
Mailing Address - Fax:708-361-3748
Practice Address - Street 1:12620 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1428
Practice Address - Country:US
Practice Address - Phone:708-361-3338
Practice Address - Fax:708-361-3748
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-004799213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU56345Medicare UPIN
IL256500Medicare ID - Type Unspecified