Provider Demographics
NPI:1104876713
Name:LIN, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LIN
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 1:110 IRVING ST NW
Mailing Address - Street 2:#2A38
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2976
Mailing Address - Country:US
Mailing Address - Phone:202-877-0333
Mailing Address - Fax:202-877-7328
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:#2A38
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:202-877-0333
Practice Address - Fax:202-877-7318
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD335692084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC025567100Medicaid
VA7118201Medicaid
MD413061800Medicaid
DC010668N79Medicare ID - Type Unspecified
DC025567100Medicaid