Provider Demographics
NPI:1083024194
Name:MARK, MICHELLE ALICIA (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ALICIA
Last Name:MARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ALICIA
Other - Last Name:YEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:702-616-5801
Mailing Address - Fax:
Practice Address - Street 1:10001 S EASTERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3908
Practice Address - Country:US
Practice Address - Phone:702-616-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL1002207Q00000X
NVDO2189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine