Healthcare Provider Details

I. General information

NPI: 1740210590
Provider Name (Legal Business Name): MARK L CAMENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 LEGACY CT
WEST BLOOMFIELD MI
48323-3634
US

IV. Provider business mailing address

22100 BOTHELL EVERETT HWY
BOTHELL WA
98021-8431
US

V. Phone/Fax

Practice location:
  • Phone: 855-687-7237
  • Fax: 855-673-9190
Mailing address:
  • Phone: 208-416-2932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101266424
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301069865
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: