Provider Demographics
NPI:1316923535
Name:SKIRGAUDAS, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:SKIRGAUDAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 94624
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6924
Mailing Address - Country:US
Mailing Address - Phone:800-634-4064
Mailing Address - Fax:952-513-6880
Practice Address - Street 1:11811 NE 128TH STREET
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7200
Practice Address - Country:US
Practice Address - Phone:425-821-3472
Practice Address - Fax:425-820-4115
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0412992085R0202X
WAMD600823352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTA2516306OtherOXFORD
CT001412999Medicaid
CT010041299CT01OtherANTHEM BC/BS
CT300003408Medicare ID - Type Unspecified
CT010041299CT01OtherANTHEM BC/BS
CTH54178Medicare UPIN