Provider Demographics
NPI:1891703997
Name:MAIOCCO, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MAIOCCO
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 1:611 N 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-6348
Mailing Address - Country:US
Mailing Address - Phone:509-249-1288
Mailing Address - Fax:509-249-6249
Practice Address - Street 1:611 N 39TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6348
Practice Address - Country:US
Practice Address - Phone:509-249-1288
Practice Address - Fax:509-249-6249
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034907207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1101831Medicaid
G61006Medicare UPIN
G8800124Medicare PIN