Provider Demographics
NPI:1124351796
Name:PYLE, MARK DWAYNE (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DWAYNE
Last Name:PYLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5406 LEARY AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4068
Mailing Address - Country:US
Mailing Address - Phone:206-784-0700
Mailing Address - Fax:206-706-8822
Practice Address - Street 1:5406 LEARY AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4068
Practice Address - Country:US
Practice Address - Phone:206-784-0700
Practice Address - Fax:206-706-8822
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60110615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1024566Medicaid
WA2014245Medicaid
WAG8909099Medicare PIN
WA6924350001Medicare NSC
WA2014245Medicaid