Provider Demographics
NPI:1871144303
Name:ONG, MARK ELTON LAO
Entity type:Individual
Prefix:
First Name:MARK ELTON
Middle Name:LAO
Last Name:ONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3761 HARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5299
Mailing Address - Country:US
Mailing Address - Phone:858-275-4132
Mailing Address - Fax:
Practice Address - Street 1:2250 PEARL ST
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-6022
Practice Address - Country:US
Practice Address - Phone:815-544-0358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist