Provider Demographics
NPI:1073609640
Name:HASTINGS, MARK THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:HASTINGS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16316 BRYANT RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4308
Mailing Address - Country:US
Mailing Address - Phone:503-699-8220
Mailing Address - Fax:503-699-7949
Practice Address - Street 1:16316 BRYANT RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4308
Practice Address - Country:US
Practice Address - Phone:503-699-8220
Practice Address - Fax:503-699-7949
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00284213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158759Medicaid
R100435Medicare ID - Type Unspecified
U66929Medicare UPIN