Provider Demographics
NPI:1215900303
Name:ANDERSON, MARK IAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:IAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:450 S KITSAP BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3738
Mailing Address - Country:US
Mailing Address - Phone:360-895-8950
Mailing Address - Fax:360-895-8980
Practice Address - Street 1:450 S KITSAP BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3738
Practice Address - Country:US
Practice Address - Phone:360-895-8950
Practice Address - Fax:360-895-8980
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053155A208800000X
WAMD60194935208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2011203Medicaid