Provider Demographics
NPI:1710041793
Name:KIVIAT, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:KIVIAT
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 84026
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-8426
Mailing Address - Country:US
Mailing Address - Phone:206-860-6656
Mailing Address - Fax:206-320-3396
Practice Address - Street 1:500 17TH AVE
Practice Address - Street 2:STEA10C
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5711
Practice Address - Country:US
Practice Address - Phone:206-860-6656
Practice Address - Fax:206-320-3396
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00010647208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1523406Medicaid
A04907Medicare UPIN