Provider Demographics
NPI:1003130832
Name:KILGORE, MARK ROBERT, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT, MICHAEL
Last Name:KILGORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:BOX 356100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6100
Practice Address - Country:US
Practice Address - Phone:206-598-1821
Practice Address - Fax:206-598-3803
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD.MD.60390372207ZP0102X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1003130832Medicaid
WA8937131Medicare PIN