Provider Demographics
NPI:1760421374
Name:COUGHENOUR, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:COUGHENOUR
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 13TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1621
Practice Address - Country:US
Practice Address - Phone:425-297-5500
Practice Address - Fax:425-297-5514
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025571207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0211179OtherLABOR AND INDUSTRY
WA8108839Medicaid
WA1018272Medicaid
WAMD00025571OtherSTATE LICENSE NUMBER
110073395OtherRAILROAD MEDICARE
WA0211179OtherLABOR AND INDUSTRY
WA8108839Medicaid
WA001259300Medicare PIN
WA115100603Medicare PIN