Provider Demographics
NPI:1306836705
Name:EGGLESTON, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:EGGLESTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:500 PORT DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1835
Mailing Address - Country:US
Mailing Address - Phone:509-758-8811
Mailing Address - Fax:509-751-1188
Practice Address - Street 1:500 PORT DRIVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1835
Practice Address - Country:US
Practice Address - Phone:509-758-8811
Practice Address - Fax:509-751-1188
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039323207W00000X
IDM8239207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010033114OtherREGENCE BLUE SHIELD OF IDAHO
WA0152789OtherLABOR & INDUSTRY
ID806011100Medicaid
WAMXXPR0054708OtherMOLINA HEALTHCARE
0000100033114OtherFEDERAL BLUE CROSS
WA24509OtherGROUP HEALTH COOPERATIVE
IDBYHD5OtherBLUE CROSS OF IDAHO
ID000010145029OtherREGENCE BLUE SHIELD OF IDAHO
WA8293425Medicaid
WA8928983OtherCRIME VICTIMES COMPENSATION ACT
ID42663OtherBLUE CROSS OF IDAHO
WA8928983OtherCRIME VICTIMES COMPENSATION ACT
ID42663OtherBLUE CROSS OF IDAHO
H36555Medicare UPIN
WAGAB21927Medicare PIN