Basic Information
| Provider Information | |||||||||
| NPI: | 1104914761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981224201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063291760 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1145 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981224201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063291760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00045081 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD00045081 | WA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0039581 | 01 | WA | LABOR AND INDUSTRIES # | OTHER | 0138SM | 01 | WA | BLUE SHIELD # | OTHER | 1002568 | 05 | WA | MEDICAID | A8430746 | 05 | WA | MEDICAID | US7684713 | 01 | WA | AETNA SPECIALIST PIN | OTHER |