Provider Demographics
NPI:1669416137
Name:GRAJCAR, MARK S (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:GRAJCAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6704
Mailing Address - Country:US
Mailing Address - Phone:208-884-0835
Mailing Address - Fax:208-367-8135
Practice Address - Street 1:2640 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6704
Practice Address - Country:US
Practice Address - Phone:208-884-0835
Practice Address - Fax:208-367-8135
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDO127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G12734Medicare UPIN