Provider Demographics
NPI:1649488123
Name:LO, MARK DERCHUEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DERCHUEN
Last Name:LO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4800 SAND POINT WAY NE, M/S B5520
Mailing Address - Street 2:SEATTLE CHILDREN'S HOSPITAL
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105
Mailing Address - Country:US
Mailing Address - Phone:206-987-2599
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE, M/S B5520
Practice Address - Street 2:SEATTLE CHILDREN'S HOSPITAL
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-987-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99569208000000X
WAMD600951542080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics