Provider Demographics
NPI:1699793968
Name:OMBRELLARO, MARK P (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:OMBRELLARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1135 116TH AVE NE STE 220
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4623
Mailing Address - Country:US
Mailing Address - Phone:425-450-7007
Mailing Address - Fax:425-450-0026
Practice Address - Street 1:1135 116TH AVE NE STE 220
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4623
Practice Address - Country:US
Practice Address - Phone:425-450-7007
Practice Address - Fax:425-450-0026
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000335022086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1098326Medicaid
WA1098326Medicaid
WAF25817Medicare UPIN