Provider Demographics
NPI:1861534075
Name:MAILHOT, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MAILHOT
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 1:21810 WILLAMETTE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3256
Mailing Address - Country:US
Mailing Address - Phone:503-994-4353
Mailing Address - Fax:503-722-5100
Practice Address - Street 1:21810 WILLAMETTE DR STE 200
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3256
Practice Address - Country:US
Practice Address - Phone:503-994-4353
Practice Address - Fax:833-975-0942
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047492207R00000X
ORMD194698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8473431Medicaid
WA8473431Medicaid
WA8863931Medicare PIN