Provider Demographics
NPI:1760424816
Name:MARCUS, GWEN (MD)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:MARCUS
Suffix:
Gender:F
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 34936
Mailing Address - Street 2:DEPT # 5006
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1936
Mailing Address - Country:US
Mailing Address - Phone:206-439-2988
Mailing Address - Fax:206-431-3939
Practice Address - Street 1:9635 17TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-2712
Practice Address - Country:US
Practice Address - Phone:206-763-5057
Practice Address - Fax:206-763-5241
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000387142080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAI72926Medicare UPIN