Healthcare Provider Details

I. General information

NPI: 1164685632
Provider Name (Legal Business Name): MARK S FAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2008
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 116TH AVE NE STE 205
BELLEVUE WA
98004-3811
US

IV. Provider business mailing address

PO BOX 741
MERCER ISLAND WA
98040-0741
US

V. Phone/Fax

Practice location:
  • Phone: 310-866-3707
  • Fax: 425-999-4858
Mailing address:
  • Phone:
  • Fax: 425-999-4858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60122545
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA112478
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberNOT YET
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: