Provider Demographics
NPI:1407935513
Name:MARK DAVID BALTER OD, PS
Entity Type:Organization
Organization Name:MARK DAVID BALTER OD, PS
Other - Org Name:NORTHWEST VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:BALTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-789-7417
Mailing Address - Street 1:2201 NW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4025
Mailing Address - Country:US
Mailing Address - Phone:206-789-7417
Mailing Address - Fax:206-789-7651
Practice Address - Street 1:2201 NW MARKET ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4025
Practice Address - Country:US
Practice Address - Phone:206-789-7417
Practice Address - Fax:206-789-7651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1411 TX152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT01512Medicare UPIN