Provider Demographics
NPI:1801832233
Name:MAR, KELVIN G (MD)
Entity Type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:G
Last Name:MAR
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 16546
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-0546
Mailing Address - Country:US
Mailing Address - Phone:206-781-6341
Mailing Address - Fax:206-781-6198
Practice Address - Street 1:5300 TALLMAN AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3932
Practice Address - Country:US
Practice Address - Phone:206-782-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76815207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A768150OtherCALOPTIMA
CAA76815OtherBLUE CROSS
CA00A768150OtherBLUE SHIELD
CA00A768150Medicaid
CA00A768151Medicare Oscar/Certification
CA00A768150Medicaid