Provider Demographics
NPI:1376506501
Name:ANDERSON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ANDERSON
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:501 SE 172ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-9542
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1723
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029121207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA211889OtherWA L & I
WAP00354423OtherRR MEDICARE
WA8459919Medicaid
WAP00354423OtherRR MEDICARE
WA8459919Medicaid