Provider Demographics
NPI:1558397406
Name:CERPA, MARIO V (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:V
Last Name:CERPA
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 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-3335
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:1415 KINCAID ST
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4126
Practice Address - Country:US
Practice Address - Phone:360-588-5550
Practice Address - Fax:360-588-5590
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8600389Medicaid
WA132724OtherLABOR & INDUSTRIES
WA8600389Medicaid
WAAB12767Medicare ID - Type Unspecified