Basic Information
| Provider Information | |||||||||
| NPI: | 1659369353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ILTIS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 5TH STREET | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5637854487 | ||||||||
| FaxNumber: | 5637856681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27823 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.