Provider Demographics
NPI:1639178114
Name:SILVER, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:SILVER
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 5870
Mailing Address - Street 2:446 OAK ST
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0234
Mailing Address - Country:US
Mailing Address - Phone:541-469-7401
Mailing Address - Fax:541-469-7083
Practice Address - Street 1:446 OAK ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9612
Practice Address - Country:US
Practice Address - Phone:541-469-7401
Practice Address - Fax:541-469-7083
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR44261QA0005X
ORMD15808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning FacilityGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR059709Medicaid
OR101489Medicare ID - Type Unspecified
OR059709Medicaid