Provider Demographics
NPI:1710108196
Name:MOCKOVAK, MICHAEL E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:MOCKOVAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 SW 16TH ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-2631
Mailing Address - Country:US
Mailing Address - Phone:360-635-5000
Mailing Address - Fax:360-635-5001
Practice Address - Street 1:1325 SE TECH CENTER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5552
Practice Address - Country:US
Practice Address - Phone:360-635-5000
Practice Address - Fax:360-635-5001
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD26938152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist