Provider Demographics
NPI:1538309117
Name:WEED, MARK CALLISTER (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CALLISTER
Last Name:WEED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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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:360-604-1762
Practice Address - Street 1:2005 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4311
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1762
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60173794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1538309117Medicaid
WAG8894551Medicare PIN