Provider Demographics
NPI:1649234543
Name:ROBERTS, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:ROBERTS
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 1:34509 9TH AVE S
Mailing Address - Street 2:STE 208
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6700
Mailing Address - Country:US
Mailing Address - Phone:253-944-3278
Mailing Address - Fax:253-944-4345
Practice Address - Street 1:34509 9TH AVE S
Practice Address - Street 2:STE 208
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6700
Practice Address - Country:US
Practice Address - Phone:253-944-3278
Practice Address - Fax:253-944-4345
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72120174400000X
WAMD00033523208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0281815OtherSTATE L&I
WA33523OtherWASHINGTON LICENSE
WA0281816OtherSTATE L&I
CA00G721201Medicaid
WA0290078OtherSTATE L&I
CAG72120OtherCALIFORNIA STATE LICENSE
CAG72120OtherCALIFORNIA STATE LICENSE
WAG8901756Medicare PIN
WAG8906703Medicare PIN
CAG72120OtherCALIFORNIA STATE LICENSE
WA0281816OtherSTATE L&I
WA0290078OtherSTATE L&I