Provider Demographics
NPI:1760470702
Name:MENDEZ VIGO, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MENDEZ VIGO
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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-944-9644
Practice Address - Street 1:143 GARDEN HOMES DR
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-9229
Practice Address - Country:US
Practice Address - Phone:509-684-3701
Practice Address - Fax:509-684-5817
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023934207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
50510OtherL&I
WA8105017Medicaid
8924175OtherL&I CRIME VICTIMS
8924175OtherL&I CRIME VICTIMS
WA000301895Medicare ID - Type Unspecified