Provider Demographics
NPI:1043294473
Name:VALENTINE, MARK CONRAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CONRAD
Last Name:VALENTINE
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 1:3327 COLBY AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-6403
Mailing Address - Country:US
Mailing Address - Phone:425-258-6767
Mailing Address - Fax:425-259-6260
Practice Address - Street 1:3327 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-6403
Practice Address - Country:US
Practice Address - Phone:425-258-6767
Practice Address - Fax:425-259-6260
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017167207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1489608Medicaid
WA1489608Medicaid