Provider Demographics
NPI:1821713645
Name:YOST, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:YOST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 NW 25TH AVE APT 501
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2764
Mailing Address - Country:US
Mailing Address - Phone:415-407-6519
Mailing Address - Fax:
Practice Address - Street 1:15405 SW 116TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:OR
Practice Address - Zip Code:97224-4101
Practice Address - Country:US
Practice Address - Phone:971-371-3927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR44277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program