Provider Demographics
NPI:1952465965
Name:BACKUS, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:BACKUS
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 1:201 16TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-5226
Mailing Address - Country:US
Mailing Address - Phone:206-326-3000
Mailing Address - Fax:
Practice Address - Street 1:201 16TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5226
Practice Address - Country:US
Practice Address - Phone:206-326-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000281592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8134835Medicaid
WAG001050880Medicare PIN
WAGAB23872Medicare PIN
WAGAB23874Medicare PIN
WAG8872227Medicare PIN
WAP00348047Medicare PIN
WAGAB23873Medicare PIN
WAGAB23875Medicare PIN
WAF17493Medicare UPIN