Provider Demographics
NPI:1649789595
Name:BEATTY, MARK EDWARD
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:BEATTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 RUCKER AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3900
Mailing Address - Country:US
Mailing Address - Phone:425-339-8799
Mailing Address - Fax:425-339-5263
Practice Address - Street 1:3020 RUCKER AVE STE 306
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3900
Practice Address - Country:US
Practice Address - Phone:425-339-8799
Practice Address - Fax:425-339-5263
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA521072083P0500X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52107OtherMEDICAL LICENSE