Provider Demographics
NPI:1689620320
Name:EVERARD, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:EVERARD
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 1:1216 PINE ST
Mailing Address - Street 2:STE 300
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101
Mailing Address - Country:US
Mailing Address - Phone:206-323-1768
Mailing Address - Fax:206-323-2184
Practice Address - Street 1:1216 PINE ST
Practice Address - Street 2:STE 300
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101
Practice Address - Country:US
Practice Address - Phone:206-323-1768
Practice Address - Fax:206-323-2184
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042194207L00000X, 2084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8366171Medicaid
WA8802269Medicare ID - Type Unspecified
H89764Medicare UPIN