Provider Demographics
NPI:1518967447
Name:SIMCHUK, MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SIMCHUK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:1619 NW HAWTHORNE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-6008
Mailing Address - Country:US
Mailing Address - Phone:541-471-7056
Mailing Address - Fax:541-474-3201
Practice Address - Street 1:1619 NW HAWTHORNE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-6008
Practice Address - Country:US
Practice Address - Phone:541-471-7056
Practice Address - Fax:541-474-3201
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00291213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150459Medicaid
OR150459Medicaid
ORU62663Medicare UPIN