Provider Demographics
NPI:1699714295
Name:HARRIS, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:HARRIS
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 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6660
Practice Address - Fax:253-426-6250
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0003796207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2169HAOtherBSWA
WA0205765OtherLIWA
WA1188HAOtherBSWA
WA5123HAOtherBSWA
WA8252967Medicaid
WA0176574OtherLIWA
WA0205764OtherLIWA
WA1126HAOtherBSWA
WA8441529Medicaid
WA0176575OtherLIWA
WA1594HAOtherBSWA
WA0205765OtherLIWA
WA1594HAOtherBSWA
E03911Medicare UPIN
WAG8853917Medicare PIN
WA0176574OtherLIWA
WA1188HAOtherBSWA
WA2169HAOtherBSWA
WAGAB16228Medicare PIN