Provider Demographics
NPI:1497728901
Name:CRADDOCK, MARK FARABEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:FARABEE
Last Name:CRADDOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4700 POINT FOSDICK DR STE 220
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1706
Mailing Address - Country:US
Mailing Address - Phone:253-851-5121
Mailing Address - Fax:253-851-3059
Practice Address - Street 1:4700 POINT FOSDICK DR
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1706
Practice Address - Country:US
Practice Address - Phone:253-851-5121
Practice Address - Fax:253-851-3059
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8344509Medicaid
WA8344509Medicaid
WA1047106Medicare ID - Type Unspecified