Provider Demographics
NPI:1710046511
Name:MAYBERG, MARC R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:R
Last Name:MAYBERG
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-542-6420
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST BOX 356165
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-5788
Practice Address - Country:US
Practice Address - Phone:206-598-7226
Practice Address - Fax:206-598-2475
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022792207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1009224Medicaid
WA0189724OtherLABOR AND INDUSTRIES
WA1710046511Medicaid
WA8806903Medicare ID - Type Unspecified
WA1710046511Medicaid
WAG8879165Medicare PIN