Provider Demographics
NPI:1730454810
Name:SHWAYDER, MARK HARRIS (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:HARRIS
Last Name:SHWAYDER
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 1:3720 SW BOND AVE
Mailing Address - Street 2:UNIT 2014
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4571
Mailing Address - Country:US
Mailing Address - Phone:310-901-4995
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:888-631-2452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1641942080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology