Provider Demographics
NPI:1356394258
Name:WHARTON, MARCIA M (MD)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:M
Last Name:WHARTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:15 SW EVERETT MALL WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-2715
Practice Address - Country:US
Practice Address - Phone:425-348-6727
Practice Address - Fax:877-860-2291
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1008489- EFF 1/19/16Medicaid
F67262Medicare UPIN
WAG8948990-EFF 1/19/16Medicare UPIN
WA1008489- EFF 1/19/16Medicaid
WAG8877632Medicare PIN