Provider Demographics
NPI:1972581114
Name:MARIANI, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MARIANI
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 1:3124 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2433
Mailing Address - Country:US
Mailing Address - Phone:253-459-7000
Mailing Address - Fax:
Practice Address - Street 1:3124 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2433
Practice Address - Country:US
Practice Address - Phone:253-459-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85025204C00000X, 207Q00000X, 207QS0010X
WAMD00046384207QS0010X, 207Q00000X, 2081S0010X, 204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I08769Medicare UPIN