Provider Demographics
NPI:1841389152
Name:BALTER, MARK D (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:BALTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 NW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4025
Mailing Address - Country:US
Mailing Address - Phone:206-789-7417
Mailing Address - Fax:206-789-7651
Practice Address - Street 1:2201 NW MARKET ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4025
Practice Address - Country:US
Practice Address - Phone:206-789-7417
Practice Address - Fax:206-789-7651
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1411TX152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA410004828OtherRAILROAD MEDICARE
WA410004828OtherRAILROAD MEDICARE
WATO 1512Medicare UPIN
WAG000100292Medicare ID - Type UnspecifiedPROVIDER NUMBER