Provider Demographics
NPI:1053534347
Name:ST MARKS EYE INSTITUTE INC
Entity type:Organization
Organization Name:ST MARKS EYE INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MACLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-627-8266
Mailing Address - Street 1:502 S 'M' ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405
Mailing Address - Country:US
Mailing Address - Phone:253-627-8266
Mailing Address - Fax:253-572-7839
Practice Address - Street 1:502 S 'M' ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-627-8266
Practice Address - Fax:253-572-7839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARKS EYE INSTITUTE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-11
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601477860207W00000X
WA14833207W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7051204Medicaid
WA7051204Medicaid
WA1147490001Medicare NSC
G001000691Medicare ID - Type Unspecified