Provider Demographics
NPI:1497826424
Name:MAKAN, NIZAR R (MD)
Entity Type:Individual
Prefix:
First Name:NIZAR
Middle Name:R
Last Name:MAKAN
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:PO BOX 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:360-752-5653
Practice Address - Street 1:4465 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8037
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5653
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40174207N00000X
WAMD00021424207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1497826424Medicaid
WA7017989OtherAETNA
WA4466MAOtherREGENCE
CA00G401740Medicaid
WA0229998OtherL&I AND CRIME VICTIMS
WA4466MAOtherREGENCE
WAG8872966Medicare PIN