Provider Demographics
NPI:1700825304
Name:HEGEWALD, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:HEGEWALD
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 1:34612 6TH AVE S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8723
Mailing Address - Country:US
Mailing Address - Phone:253-661-2594
Mailing Address - Fax:253-661-2694
Practice Address - Street 1:34612 6TH AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8723
Practice Address - Country:US
Practice Address - Phone:253-661-2594
Practice Address - Fax:253-661-2694
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025475207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1427128198OtherGROUP NPI
WA1056662Medicaid
8850240Medicare ID - Type Unspecified
WA1056662Medicaid
A08750Medicare UPIN