Provider Demographics
NPI:1588720510
Name:OUELLETTE, MARK (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:OUELLETTE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 WILLAGILLESPIE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6729
Mailing Address - Country:US
Mailing Address - Phone:541-636-4471
Mailing Address - Fax:541-357-4992
Practice Address - Street 1:1144 WILLAGILLESPIE RD
Practice Address - Street 2:STE 1
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6729
Practice Address - Country:US
Practice Address - Phone:541-636-4471
Practice Address - Fax:541-357-4492
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR160426OtherMEDICARE ID#
OR5006612413Medicaid