Provider Demographics
NPI:1518998327
Name:MONAHAN, MARK TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:TIMOTHY
Last Name:MONAHAN
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 1:403 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3116
Mailing Address - Country:US
Mailing Address - Phone:815-288-5531
Mailing Address - Fax:815-285-5558
Practice Address - Street 1:403 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3116
Practice Address - Country:US
Practice Address - Phone:815-288-5531
Practice Address - Fax:815-285-5558
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057437A207P00000X
IL036107925207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4782693Medicaid
IL036109925OtherPHYSICIAN LICENSE
IN200432460Medicaid
IN000000282214OtherANTHEM PIN