Provider Demographics
NPI:1225147200
Name:YOVICHIN, MARK DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANIEL
Last Name:YOVICHIN
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 1:927 E POLSTON AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-9390
Mailing Address - Country:US
Mailing Address - Phone:208-664-3313
Mailing Address - Fax:208-664-2793
Practice Address - Street 1:750 N SYRINGA ST STE 100
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-777-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDH02127Medicare UPIN