Provider Demographics
NPI:1811292444
Name:HARTFORD, MARK (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HARTFORD
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 1:5904 NE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4941
Mailing Address - Country:US
Mailing Address - Phone:323-326-6120
Mailing Address - Fax:
Practice Address - Street 1:7101 NE 137TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-4933
Practice Address - Country:US
Practice Address - Phone:360-418-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06498225100000X
WAPT60615104225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEP032YMedicare PIN