Provider Demographics
NPI:1316961659
Name:ANDERSON, MARK T (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1025 153RD ST SE
Mailing Address - Street 2:STE 200
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-4051
Mailing Address - Country:US
Mailing Address - Phone:425-745-4750
Mailing Address - Fax:425-745-6158
Practice Address - Street 1:1025 153RD ST SE
Practice Address - Street 2:SUITE 200
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-4051
Practice Address - Country:US
Practice Address - Phone:425-745-4750
Practice Address - Fax:425-745-6158
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2017-12-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00019962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8855178Medicare ID - Type Unspecified
WAA09317Medicare UPIN