Individual
MARIO L GOSPODINOFF
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1301 ENTERPRISE WAY, MARION, IL 62959-4442
(618) 993-1122
Mailing address
1301 ENTERPRISE WAY, MARION, IL 62959-4442
(618) 993-1122
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
036040279
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036040279
—
IL
05
—
370966854011
—
IL
Enumeration date
12/07/2005
Last updated
04/20/2011
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