Provider Demographics
NPI:1700890597
Name:HAUGEN, MARK DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:HAUGEN
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 1:55 WEST TIETAN STREET
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1592
Practice Address - Street 1:55 WEST TIETAN STREET
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4445
Practice Address - Country:US
Practice Address - Phone:509-525-3720
Practice Address - Fax:509-522-1592
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.082702207Q00000X
WAMD60024498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2425736Medicaid
OHHA7315251Medicare ID - Type Unspecified
OH2425736Medicaid
OHH92149Medicare UPIN