Basic Information
| Provider Information | |||||||||
| NPI: | 1073509766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEKOLA | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622264725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182352400 | ||||||||
| FaxNumber: | 6182350900 | ||||||||
| Practice Location | |||||||||
| Address1: | 3990 N ILLINOIS ST | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622261919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182771130 | ||||||||
| FaxNumber: | 6182774917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 09/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 036092365 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 08215191 | 01 | IL | BCBS | OTHER | 036092365 | 05 | IL | MEDICAID | 18007717 | 01 | RR MEDICARE | OTHER |