Provider Demographics
NPI:1770511438
Name:PECKLER, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:PECKLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3525 ENSIGN RD NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5065
Mailing Address - Country:US
Mailing Address - Phone:360-456-4666
Mailing Address - Fax:360-459-1566
Practice Address - Street 1:3525 ENSIGN RD.
Practice Address - Street 2:SUITE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98505-0001
Practice Address - Country:US
Practice Address - Phone:360-456-4666
Practice Address - Fax:360-459-1566
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00019049208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA17815OtherLABOR AND INDUSTRIES
WA1789601Medicaid
WAT00100OtherREGENCE
WAG001048501OtherPTAN
WAT00100OtherREGENCE
WAA08851Medicare UPIN