Provider Demographics
NPI:1609815166
Name:HALL, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HALL
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 1:388 SW BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1360
Mailing Address - Country:US
Mailing Address - Phone:541-678-0020
Mailing Address - Fax:541-323-2174
Practice Address - Street 1:388 SW BLUFF DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1360
Practice Address - Country:US
Practice Address - Phone:541-678-0020
Practice Address - Fax:541-323-2174
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26648207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241835Medicaid
ORR134890Medicare PIN
OR241835Medicaid