Provider Demographics
NPI:1225060296
Name:EVERETT, MARK G (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:EVERETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:16818 E DESMET CT
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3542
Practice Address - Country:US
Practice Address - Phone:509-456-5380
Practice Address - Fax:509-456-5381
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003015152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1005298Medicaid
ID0043183Medicaid
WA410022656OtherRAIL ROAD MEDICARE
ID410045028OtherRAIL ROAD MEDICARE
WA410045027OtherRAIL ROAD MEDICARE
WAG000686616Medicare PIN
WA410022656OtherRAIL ROAD MEDICARE
WAG000355070Medicare PIN
WA410045027OtherRAIL ROAD MEDICARE
WAG001056821Medicare PIN
WAG319209202Medicare PIN
ID1592714Medicare PIN