Provider Demographics
NPI:1972595551
Name:MCEATHRON, MARK GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GEORGE
Last Name:MCEATHRON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 E MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4510
Mailing Address - Country:US
Mailing Address - Phone:360-647-2020
Mailing Address - Fax:360-752-1771
Practice Address - Street 1:411 E MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4510
Practice Address - Country:US
Practice Address - Phone:360-647-2020
Practice Address - Fax:360-752-1771
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1381152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2027548Medicaid
WAU21205Medicare UPIN
WAGAB18812Medicare PIN
WA0199020001Medicare NSC