Provider Demographics
NPI:1962575951
Name:PELLICCIARO, MARC D (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:D
Last Name:PELLICCIARO
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 1:12729 NORTHUP WAY STE 6
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-1935
Mailing Address - Country:US
Mailing Address - Phone:425-467-1000
Mailing Address - Fax:425-467-0100
Practice Address - Street 1:12729 NORTHUP WAY STE 6
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-1935
Practice Address - Country:US
Practice Address - Phone:425-467-1000
Practice Address - Fax:425-467-0100
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2019-04-17
Deactivation Date:2018-05-09
Deactivation Code:
Reactivation Date:2018-05-16
Provider Licenses
StateLicense IDTaxonomies
WAMD 000368132084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2652Medicaid